Provider Demographics
NPI:1669680765
Name:KELLY, TERESA COLLEEN (DC)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:COLLEEN
Last Name:KELLY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 DURRELL ST
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:NJ
Mailing Address - Zip Code:07044-1722
Mailing Address - Country:US
Mailing Address - Phone:973-777-9404
Mailing Address - Fax:973-777-9489
Practice Address - Street 1:657 VAN HOUTEN AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-2134
Practice Address - Country:US
Practice Address - Phone:973-777-9404
Practice Address - Fax:973-777-9489
Is Sole Proprietor?:No
Enumeration Date:2007-05-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00545600111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8038708Medicaid
NJU76355Medicare UPIN
NJ8038708Medicaid