Provider Demographics
NPI:1891923645
Name:STANKIEWICZ, KELLY K (PHD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:K
Last Name:STANKIEWICZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:K
Other - Last Name:KOUKOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08876-2320
Mailing Address - Country:US
Mailing Address - Phone:908-307-1842
Mailing Address - Fax:
Practice Address - Street 1:21 E HIGH ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08876-2320
Practice Address - Country:US
Practice Address - Phone:908-307-1842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00468300103T00000X
PAPS016490103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist