Healthcare Provider Details

I. General information

NPI: 1376189480
Provider Name (Legal Business Name): KELLY AMANIERA ATR-BC, NCC, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2019
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 E MIDLAND AVE
PARAMUS NJ
07652-2920
US

IV. Provider business mailing address

101 SHERWOOD ST
CLIFTON NJ
07013-1307
US

V. Phone/Fax

Practice location:
  • Phone: 551-223-0571
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number17-254
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00721900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: