Provider Demographics
NPI:1306506472
Name:VENEZIA CRILLY, KELLY E (LAC, NCC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:E
Last Name:VENEZIA CRILLY
Suffix:
Gender:F
Credentials:LAC, NCC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:VENEZIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:29 HIBERNIA RD
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07866-1824
Mailing Address - Country:US
Mailing Address - Phone:862-377-4172
Mailing Address - Fax:
Practice Address - Street 1:860 WYCKOFF AVE STE 206&305
Practice Address - Street 2:
Practice Address - City:MAHWAH
Practice Address - State:NJ
Practice Address - Zip Code:07430-3186
Practice Address - Country:US
Practice Address - Phone:551-319-2029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1086514101YS0200X
NJ37AC00614600101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool