Provider Demographics
NPI:1386319960
Name:SALLIE, KELLY A (LCADC, CPRS, CCTP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:SALLIE
Suffix:
Gender:F
Credentials:LCADC, CPRS, CCTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 240
Mailing Address - Street 2:
Mailing Address - City:MOUNT TABOR
Mailing Address - State:NJ
Mailing Address - Zip Code:07878-0240
Mailing Address - Country:US
Mailing Address - Phone:973-404-0214
Mailing Address - Fax:
Practice Address - Street 1:14 HILSINGER RD # 240
Practice Address - Street 2:
Practice Address - City:MOUNT TABOR
Practice Address - State:NJ
Practice Address - Zip Code:07878-9226
Practice Address - Country:US
Practice Address - Phone:973-404-0214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-15
Last Update Date:2021-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00331800101Y00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor