Healthcare Provider Details

I. General information

NPI: 1861305286
Provider Name (Legal Business Name): KELLY MARIE OWEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2114 BRANDEIS AVE
CINNAMINSON NJ
08077-3513
US

IV. Provider business mailing address

2114 BRANDEIS AVE
CINNAMINSON NJ
08077-3513
US

V. Phone/Fax

Practice location:
  • Phone: 609-781-2478
  • Fax:
Mailing address:
  • Phone: 609-781-2478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number15BC00301300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: