=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992244149
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY HENNEBRY LCSW, LCADC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2017
-----------------------------------------------------
Last Update Date | 09/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 MADISON AVE STE 220
-----------------------------------------------------
City | MORRISTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07960-6967
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-267-1238
-----------------------------------------------------
Fax | 973-540-8849
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 95 WEST MAIN STREET SUITE 5 #233 SUITE 5 #233
-----------------------------------------------------
City | CHESTER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-796-3810
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 37LC00299600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 44SC05894700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------