Provider Demographics
NPI:1639473465
Name:KOELLER, KELLY (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KOELLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:HANSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 834
Mailing Address - Street 2:
Mailing Address - City:SADDLE RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07458-0834
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 REHILL AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08876-2519
Practice Address - Country:US
Practice Address - Phone:908-203-5961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-09
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC056933001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical