Provider Demographics
NPI:1366954919
Name:KELLISH, ALEXANDER
Entity type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:
Last Name:KELLISH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 BRUSH HILL RD
Mailing Address - Street 2:
Mailing Address - City:KINNELON
Mailing Address - State:NJ
Mailing Address - Zip Code:07405-2421
Mailing Address - Country:US
Mailing Address - Phone:917-912-9618
Mailing Address - Fax:
Practice Address - Street 1:23 BRUSH HILL RD
Practice Address - Street 2:
Practice Address - City:KINNELON
Practice Address - State:NJ
Practice Address - Zip Code:07405-2421
Practice Address - Country:US
Practice Address - Phone:917-912-9618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-03
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator