Provider Demographics
NPI:1750526729
Name:RETTBERG, KELLY ANN (LPC)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:RETTBERG
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:MCGARVEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:319 MANOR LN BLDG S
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4154
Mailing Address - Country:US
Mailing Address - Phone:267-982-3928
Mailing Address - Fax:
Practice Address - Street 1:319 MANOR LN BLDG S
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-4154
Practice Address - Country:US
Practice Address - Phone:267-982-3928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-04
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00375200101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4138601Medicaid
NJ310050Medicare UPIN