Provider Demographics
NPI:1871779355
Name:KENNELLY, CARYN J (PSYD)
Entity type:Individual
Prefix:DR
First Name:CARYN
Middle Name:J
Last Name:KENNELLY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 CONCORD PL
Mailing Address - Street 2:
Mailing Address - City:PENNINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08534-5265
Mailing Address - Country:US
Mailing Address - Phone:609-947-2116
Mailing Address - Fax:
Practice Address - Street 1:2571 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-1657
Practice Address - Country:US
Practice Address - Phone:609-947-2116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ3997103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ052287OtherMEDICARE ID