=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295369668
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KELLY MCGLYNN, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2020
-----------------------------------------------------
Last Update Date | 02/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4446 ROUTE 27 STE 1
-----------------------------------------------------
City | KINGSTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08528-9613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-451-0085
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 191
-----------------------------------------------------
City | ROCKY HILL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08553-0191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-451-0085
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KELLY J MCGLYNN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 609-647-2280
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------