Healthcare Provider Details

I. General information

NPI: 1124117007
Provider Name (Legal Business Name): KELLY CANZONE, LCSW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 - 131 RT. 183 NORTH 2ND FLOOR, SUITE 2
STANHOPE NJ
07874
US

IV. Provider business mailing address

8 W LAKE DR
STANHOPE NJ
07874-3018
US

V. Phone/Fax

Practice location:
  • Phone: 973-886-2222
  • Fax:
Mailing address:
  • Phone: 973-886-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05283700
License Number StateNJ

VIII. Authorized Official

Name: MRS. KELLY CLARE CANZONE
Title or Position: OWNER
Credential: LCSW
Phone: 973-886-2222