Kelly Redkoles

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

44SC05386600 Issued in NJ

Practice address

901 Mantua Pike
BLDG a Suite 103
West Deptford, NJ 08096

Phone

(856) 294-6711

NPI assigned

Apr 11, 2007

Last updated

Mar 31, 2021By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Opted out of Medicare

Yes, effective Dec 11, 2023 through Dec 11, 2027

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Unstuck Therapy

  • Clinical Social Worker
  • West Deptford, NJ
  • NPI 1861822306
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1176249600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1617148800000",
    "number": "1578786240",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "119 WHEATLEY BLVD",
            "city": "MULLICA HILL",
            "state": "NJ",
            "postal_code": "080629605",
            "telephone_number": "856-889-5902"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "901 MANTUA PIKE",
            "address_2": "BLDG A SUITE 103",
            "city": "WEST DEPTFORD",
            "state": "NJ",
            "postal_code": "08096",
            "telephone_number": "856-294-6711"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "REDKOLES",
        "first_name": "KELLY",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2007-04-11",
        "last_updated": "2021-03-31",
        "certification_date": "2021-03-31",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "104100000X",
            "taxonomy_group": "",
            "desc": "Social Worker",
            "state": "NJ",
            "license": "44SL05393200",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "NJ",
            "license": "44SC05386600",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Premiere Dental of West Deptford
• Pro Chiropractic LLC
• Eli Prowe, D.C.
• Jennifer Quimby, ME.D., BCBA
• Austin Redfearn
• Renewed Light LLC
• Natalie Rios, RN, CPNP
• Rise Home Therapy, LLC
• Amber Elizabeth Rishel, LSW
• Rite Aid of New Jersey Inc (Rite Aid Pharmacy 04094)

• Clinical Social Worker in West Deptford, NJ
• Providers in West Deptford, NJ by specialty
• Clinical Social Worker in New Jersey

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 31, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.