Provider Demographics
NPI:1003467267
Name:KELLY JOHN, MARTRELL DENISE (LISW-CP)
Entity Type:Individual
Prefix:
First Name:MARTRELL
Middle Name:DENISE
Last Name:KELLY JOHN
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 HARMONY DR
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-5729
Mailing Address - Country:US
Mailing Address - Phone:240-463-7794
Mailing Address - Fax:
Practice Address - Street 1:250 COMMONWEALTH DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4846
Practice Address - Country:US
Practice Address - Phone:240-463-7794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC103261041C0700X
MD145821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical