Provider Demographics
NPI:1003498122
Name:SELF, KERRIE MARIE (RVT,RBT)
Entity Type:Individual
Prefix:
First Name:KERRIE
Middle Name:MARIE
Last Name:SELF
Suffix:
Gender:F
Credentials:RVT,RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 LARRY DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:LAWNDALE
Mailing Address - State:NC
Mailing Address - Zip Code:28090-8419
Mailing Address - Country:US
Mailing Address - Phone:828-308-3723
Mailing Address - Fax:
Practice Address - Street 1:910 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-3449
Practice Address - Country:US
Practice Address - Phone:704-748-0616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst