Provider Demographics
NPI:1841946001
Name:KELLY, LAURA (PSYD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 WHATLEY RD
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08690-3123
Mailing Address - Country:US
Mailing Address - Phone:609-529-6121
Mailing Address - Fax:
Practice Address - Street 1:100 STRAUBE CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PENNINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08534-1468
Practice Address - Country:US
Practice Address - Phone:609-737-7797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-26
Last Update Date:2022-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00646300103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist