Healthcare Provider Details

I. General information

NPI: 1669580395
Provider Name (Legal Business Name): KELLY LYNN GILRAIN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 07/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 COOPER PLZ SUITE 307
CAMDEN NJ
08103-1438
US

IV. Provider business mailing address

3 COOPER PLZ SUITE 307
CAMDEN NJ
08103-1438
US

V. Phone/Fax

Practice location:
  • Phone: 856-342-2328
  • Fax: 856-541-6137
Mailing address:
  • Phone: 856-342-2328
  • Fax: 856-541-6137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS016078
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS016078
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberSI00445800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: