Healthcare Provider Details

I. General information

NPI: 1346705894
Provider Name (Legal Business Name): KEVIN ELSEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2019
Last Update Date: 03/04/2022
Certification Date: 03/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 HIGHLAND AVE STE C
HADDON TOWNSHIP NJ
08108-2634
US

IV. Provider business mailing address

19 TARA DR
MOUNT LAUREL NJ
08054-9588
US

V. Phone/Fax

Practice location:
  • Phone: 856-854-3155
  • Fax:
Mailing address:
  • Phone: 609-929-5737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number37AC00344600
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00745900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: