Provider Demographics
NPI:1285492413
Name:BELLOMO, KEITH J (LAC)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:J
Last Name:BELLOMO
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 MEEKER AVE
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-5203
Mailing Address - Country:US
Mailing Address - Phone:267-266-7251
Mailing Address - Fax:
Practice Address - Street 1:380 FOOTHILL RD
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:08807-2255
Practice Address - Country:US
Practice Address - Phone:908-231-0511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00767600101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health