Provider Demographics
NPI:1598270571
Name:MEDVIN, KELLY (LPC, NCC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:MEDVIN
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:NJ
Mailing Address - Zip Code:07928-1369
Mailing Address - Country:US
Mailing Address - Phone:973-655-0220
Mailing Address - Fax:973-655-0220
Practice Address - Street 1:268 GREEN VILLAGE RD
Practice Address - Street 2:
Practice Address - City:GREEN VILLAGE
Practice Address - State:NJ
Practice Address - Zip Code:07935-3027
Practice Address - Country:US
Practice Address - Phone:917-922-1693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00585800101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health