Provider Demographics
NPI:1417466590
Name:MCCORKLE, KELLY ANN (LPC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:MCCORKLE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 BROADWAY STE 200H
Mailing Address - Street 2:
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-2739
Mailing Address - Country:US
Mailing Address - Phone:973-464-5882
Mailing Address - Fax:
Practice Address - Street 1:76 BROADWAY STE 200H
Practice Address - Street 2:
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-2739
Practice Address - Country:US
Practice Address - Phone:973-464-5882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00603200101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional