Provider Demographics
NPI:1689984007
Name:SECCAMANIE, KELLY M
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:M
Last Name:SECCAMANIE
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 1:78 BAKER AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY HTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07922-1302
Mailing Address - Country:US
Mailing Address - Phone:908-507-0455
Mailing Address - Fax:908-580-9745
Practice Address - Street 1:1 MOUNTAIN BOULEVARD
Practice Address - Street 2:EXECUTIVE PLAZA SUITE 201
Practice Address - City:WARREN
Practice Address - State:NJ
Practice Address - Zip Code:07059
Practice Address - Country:US
Practice Address - Phone:908-507-0455
Practice Address - Fax:908-580-9745
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14392101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral