Provider Demographics
NPI:1659081800
Name:MIECZKOWSKI, KELSEY LYNN
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:LYNN
Last Name:MIECZKOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1944 SHIP CT
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-3119
Mailing Address - Country:US
Mailing Address - Phone:908-930-5688
Mailing Address - Fax:
Practice Address - Street 1:1433 HOOPER AVE
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-2242
Practice Address - Country:US
Practice Address - Phone:844-234-8387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-29
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR01097300225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist