Provider Demographics
NPI:1043555725
Name:SLAGGERT, KELLYE HUTTON
Entity Type:Individual
Prefix:
First Name:KELLYE
Middle Name:HUTTON
Last Name:SLAGGERT
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 1:169 KINGS CROSS LN
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-5906
Mailing Address - Country:US
Mailing Address - Phone:704-608-6812
Mailing Address - Fax:
Practice Address - Street 1:18047 W CATAWBA AVE STE 203
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-5688
Practice Address - Country:US
Practice Address - Phone:704-608-6812
Practice Address - Fax:704-696-7975
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-06
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9122101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301007938OtherSTATE OF MICHIGAN BOARD OF PSYCHOLOGY
NCLPC911OtherNORTH CAROLINA LPC