Provider Demographics
NPI:1700478724
Name:WALES, KELLY (EDS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WALES
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 BLOSSOM ST
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-4213
Mailing Address - Country:US
Mailing Address - Phone:908-307-5964
Mailing Address - Fax:
Practice Address - Street 1:18 BLOSSOM ST
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08817-4213
Practice Address - Country:US
Practice Address - Phone:908-307-5964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool