Provider Demographics
NPI:1871208793
Name:KELLY, VICTORIA GRACE (PSYD)
Entity type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:GRACE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 ELIZABETH ST UNIT 111
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOUND BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08880-1273
Mailing Address - Country:US
Mailing Address - Phone:908-752-3471
Mailing Address - Fax:
Practice Address - Street 1:312 AMBOY AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:METUCHEN
Practice Address - State:NJ
Practice Address - Zip Code:08840-2455
Practice Address - Country:US
Practice Address - Phone:848-219-2874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-16
Last Update Date:2023-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00698100103T00000X
PAPS019800103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist