Provider Demographics
NPI:1124630355
Name:BOCCIO, KELLY THERESA (MA, NCC, LAC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:THERESA
Last Name:BOCCIO
Suffix:
Gender:F
Credentials:MA, NCC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 POWELL RD
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07401-2011
Mailing Address - Country:US
Mailing Address - Phone:718-619-5454
Mailing Address - Fax:
Practice Address - Street 1:79 N FRANKLIN TPKE STE 107
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:NJ
Practice Address - Zip Code:07446-2029
Practice Address - Country:US
Practice Address - Phone:973-477-5480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00531400101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty