Provider Demographics
NPI:1043564453
Name:BOLLINGER, KELLY MOZELLE (MED LPC CACII)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:MOZELLE
Last Name:BOLLINGER
Suffix:
Gender:F
Credentials:MED LPC CACII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29625-3541
Mailing Address - Country:US
Mailing Address - Phone:864-525-2197
Mailing Address - Fax:
Practice Address - Street 1:735 MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29634-4022
Practice Address - Country:US
Practice Address - Phone:864-656-2451
Practice Address - Fax:864-656-0760
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-07
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5043101Y00000X, 101YM0800X, 101YP2500X
SC1102244101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional