Provider Demographics
NPI:1912761883
Name:CAMPBELL, KELLY JEAN (BCABA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 FORT DE FRANCE
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08757
Mailing Address - Country:US
Mailing Address - Phone:973-229-4512
Mailing Address - Fax:
Practice Address - Street 1:52 FORT DE FRANCE
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08757
Practice Address - Country:US
Practice Address - Phone:973-229-4512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0-18-8909106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst