Healthcare Provider Details

I. General information

NPI: 1497902209
Provider Name (Legal Business Name): KELLY LYNN STOLBERG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2008
Last Update Date: 12/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 WITHERSPOON ST EATING DISORDERS PROGRAM
PRINCETON NJ
08540-3211
US

IV. Provider business mailing address

253 WITHERSPOON ST EATING DISORDERS PROGRAM
PRINCETON NJ
08540-3211
US

V. Phone/Fax

Practice location:
  • Phone: 609-497-4000
  • Fax: 609-497-4412
Mailing address:
  • Phone: 609-497-4000
  • Fax: 609-497-4412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL05505400
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05445400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: