Provider Demographics
NPI:1578786240
Name:REDKOLES, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:REDKOLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 WHEATLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:MULLICA HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08062-9605
Mailing Address - Country:US
Mailing Address - Phone:856-889-5902
Mailing Address - Fax:
Practice Address - Street 1:901 MANTUA PIKE
Practice Address - Street 2:BLDG A SUITE 103
Practice Address - City:WEST DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08096
Practice Address - Country:US
Practice Address - Phone:856-294-6711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05393200104100000X
1041C0700X
NJ44SC053866001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker