Provider Demographics
NPI:1992244149
Name:HENNEBRY, KELLY (LCSW, LCADC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HENNEBRY
Suffix:
Gender:F
Credentials:LCSW, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 WEST MAIN STREET SUITE 5 #233
Mailing Address - Street 2:SUITE 5 #233
Mailing Address - City:CHESTER
Mailing Address - State:NJ
Mailing Address - Zip Code:07930
Mailing Address - Country:US
Mailing Address - Phone:973-796-3810
Mailing Address - Fax:
Practice Address - Street 1:310 MADISON AVE STE 220
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-6967
Practice Address - Country:US
Practice Address - Phone:973-267-1238
Practice Address - Fax:973-540-8849
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-21
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00299600101YA0400X
NJ44SC058947001041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical