Healthcare Provider Details

I. General information

NPI: 1689146193
Provider Name (Legal Business Name): KELLY SHOPE MA,LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2018
Last Update Date: 12/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 KINGS HWY STE 100
WEST DEPTFORD NJ
08096-3165
US

IV. Provider business mailing address

882 WASHINGTON AVE
FRANKLINVILLE NJ
08322-2823
US

V. Phone/Fax

Practice location:
  • Phone: 856-251-0500
  • Fax: 856-797-4785
Mailing address:
  • Phone: 856-516-4933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00215500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: