Provider Demographics
NPI:1689188609
Name:WOLF, KELLY R (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:R
Last Name:WOLF
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 DUNCAN ST
Mailing Address - Street 2:
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1204
Mailing Address - Country:US
Mailing Address - Phone:973-495-1834
Mailing Address - Fax:
Practice Address - Street 1:22 DUNCAN ST
Practice Address - Street 2:
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1204
Practice Address - Country:US
Practice Address - Phone:973-495-1834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC052614001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical