Provider Demographics
NPI:1871978833
Name:KOLLIAS, KELLY ELIZABETH (PSYD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ELIZABETH
Last Name:KOLLIAS
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 1:1 HARROWGATE CT
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4503
Mailing Address - Country:US
Mailing Address - Phone:610-247-1442
Mailing Address - Fax:
Practice Address - Street 1:3900 CHURCH ROAD
Practice Address - Street 2:BANCROFT NEUROREHAB
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-9999
Practice Address - Country:US
Practice Address - Phone:856-524-7412
Practice Address - Fax:856-216-9240
Is Sole Proprietor?:No
Enumeration Date:2015-07-20
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00547700103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical