Provider Demographics
NPI:1043606312
Name:TERRY, KELLY (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:TERRY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10535 CRESTWOOD DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-4416
Mailing Address - Country:US
Mailing Address - Phone:703-492-2686
Mailing Address - Fax:
Practice Address - Street 1:10535 CRESTWOOD DR
Practice Address - Street 2:SUITE 201
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-4416
Practice Address - Country:US
Practice Address - Phone:703-492-2686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-13
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
VA09040096681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical