Provider Demographics
NPI:1770019499
Name:NILSEN, KELLY (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:NILSEN
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-2504
Mailing Address - Country:US
Mailing Address - Phone:201-444-3550
Mailing Address - Fax:
Practice Address - Street 1:334 KINDERKAMACK RD
Practice Address - Street 2:
Practice Address - City:ORADELL
Practice Address - State:NJ
Practice Address - Zip Code:07649-2102
Practice Address - Country:US
Practice Address - Phone:201-614-5217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06213400104100000X
NJ44SC058667001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker