Provider Demographics
NPI:1720463946
Name:DEEGAN, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DEEGAN
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 1:42 S. DELSEA DR
Mailing Address - Street 2:
Mailing Address - City:GLASSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-2621
Mailing Address - Country:US
Mailing Address - Phone:856-881-8689
Mailing Address - Fax:
Practice Address - Street 1:42 S. DELSEA DR
Practice Address - Street 2:
Practice Address - City:GLASSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08081-2621
Practice Address - Country:US
Practice Address - Phone:856-881-8689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC05533000101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional