Provider Demographics
NPI:1023525094
Name:SHEEHAN, KELLY ELIZABETH I
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH
Last Name:SHEEHAN
Suffix:I
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 1:3 CLIFFORD LN
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4723
Mailing Address - Country:US
Mailing Address - Phone:609-413-0571
Mailing Address - Fax:
Practice Address - Street 1:272 DUNNS MILL RD STE 145
Practice Address - Street 2:
Practice Address - City:BORDENTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08505-4748
Practice Address - Country:US
Practice Address - Phone:877-315-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician