Provider Demographics
NPI:1336874163
Name:TEDESCO, KELLY M (LPC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:TEDESCO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:347 LINCOLN AVE E STE 2B
Mailing Address - Street 2:
Mailing Address - City:CRANFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07016-6100
Mailing Address - Country:US
Mailing Address - Phone:862-206-6861
Mailing Address - Fax:
Practice Address - Street 1:830 MORRIS TPKE STE 405
Practice Address - Street 2:
Practice Address - City:SHORT HILLS
Practice Address - State:NJ
Practice Address - Zip Code:07078-2620
Practice Address - Country:US
Practice Address - Phone:862-206-6861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-17
Last Update Date:2024-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00920600101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional