Provider Demographics
NPI:1518198076
Name:BASSETT, KELLY LYNN (LP, MED)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:LYNN
Last Name:BASSETT
Suffix:
Gender:M
Credentials:LP, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SHEPPARD RD
Mailing Address - Street 2:SUITE 704
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-4608
Mailing Address - Country:US
Mailing Address - Phone:646-510-1593
Mailing Address - Fax:
Practice Address - Street 1:1 SHEPPARD RD
Practice Address - Street 2:SUITE 704
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4608
Practice Address - Country:US
Practice Address - Phone:646-510-1593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-31
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000913102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst