MEDICARE: MRS. KATHLEEN SHELLEY LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	44SC05864800	NJ

General Provider Information

NPI Number	:	1023659331
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATHLEEN SHELLEY LCSW

Provider Business Mailing Address
First Line	:	22 ROBERTSON RD
Second Line	:
City	:	WEST ORANGE
State	:	NJ
Zip	:	07052-3519
Country	:	US
Telephone Number	:	973-809-6574
Fax Number	:

Provider Business Practice Location Address
First Line	:	22 ROBERTSON RD
Second Line	:
City	:	WEST ORANGE
State	:	NJ
Zip	:	07052-3519
Country	:	US
Telephone Number	:	973-809-6574
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/08/2019
Last Update Date	:	10/08/2019

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