Provider Demographics
NPI:1356044820
Name:KELLY, KELLY DAWN (LSW)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:DAWN
Last Name:KELLY
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2360 ROUTE 33 STE 112-219
Mailing Address - Street 2:
Mailing Address - City:ROBBINSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08691-1415
Mailing Address - Country:US
Mailing Address - Phone:914-539-7090
Mailing Address - Fax:
Practice Address - Street 1:41 BROWNSTONE WAY
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-1210
Practice Address - Country:US
Practice Address - Phone:914-539-7090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-23
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06876400104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker