Provider Demographics
NPI:1730702218
Name:NYDEGGER, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:NYDEGGER
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 1:529 CONARROE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-1629
Mailing Address - Country:US
Mailing Address - Phone:484-529-0944
Mailing Address - Fax:
Practice Address - Street 1:950 E HAVERFORD RD STE 100A
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3850
Practice Address - Country:US
Practice Address - Phone:267-223-6380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC009208101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional