Provider Demographics
NPI:1417367087
Name:NEWHART, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:NEWHART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301A RALSTON DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-3354
Mailing Address - Country:US
Mailing Address - Phone:856-234-6701
Mailing Address - Fax:
Practice Address - Street 1:113 NEW JERSEY 73
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043
Practice Address - Country:US
Practice Address - Phone:856-809-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00258000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QB00258000OtherPTA LICENSE