Provider Demographics
NPI:1659178671
Name:KPELLY, AFI TINA ALINE
Entity type:Individual
Prefix:
First Name:AFI TINA
Middle Name:ALINE
Last Name:KPELLY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 3RD AVE W UPPR
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-3725
Mailing Address - Country:US
Mailing Address - Phone:973-342-1668
Mailing Address - Fax:
Practice Address - Street 1:405 3RD AVE W UPPR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-3725
Practice Address - Country:US
Practice Address - Phone:973-342-1668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-27
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00858700101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health