MEDICARE: KELLY A SALLIE LCADC, CPRS, CCTP

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	101Y00000X	Counselor	37LC00331800	NJ
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	37LC00331800	NJ

General Provider Information

NPI Number	:	1386319960
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY A SALLIE LCADC, CPRS, CCTP

Provider Business Mailing Address
First Line	:	PO BOX 240
Second Line	:
City	:	MOUNT TABOR
State	:	NJ
Zip	:	07878-0240
Country	:	US
Telephone Number	:	973-404-0214
Fax Number	:

Provider Business Practice Location Address
First Line	:	14 HILSINGER RD # 240
Second Line	:
City	:	MOUNT TABOR
State	:	NJ
Zip	:	07878-9226
Country	:	US
Telephone Number	:	973-404-0214
Fax Number	:

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

Provider Enumeration Date	:	08/15/2021
Last Update Date	:	08/15/2021

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