Provider Demographics
NPI:1255985180
Name:DYCKMAN, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DYCKMAN
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 1:17 MANNING ST
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-5518
Mailing Address - Country:US
Mailing Address - Phone:908-463-7357
Mailing Address - Fax:
Practice Address - Street 1:705 GINESI DR
Practice Address - Street 2:
Practice Address - City:MORGANVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07751-1235
Practice Address - Country:US
Practice Address - Phone:732-993-7261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-29
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC058303001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty