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General NPI Number Information
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NPI Number | 1124630355
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Entity Type | Individual
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Provider Name | KELLY THERESA BOCCIO MA, NCC, LAC
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Gender | Female
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Dates
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Enumeration Date | 08/19/2020
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Last Update Date | 08/19/2020
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Provider Practice Location Address
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Address Line | 79 N FRANKLIN TPKE STE 107
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City | RAMSEY
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State | NJ
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Zip | 07446-2029
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Country | US
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Telephone | 973-477-5480
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Fax |
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Provider Business Mailing Address
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Address Line | 32 POWELL RD
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City | ALLENDALE
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State | NJ
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Zip | 07401-2011
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Country | US
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Telephone | 718-619-5454
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 37AC00531400
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License Number State | NJ
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