Provider Demographics
NPI:1073534384
Name:KELLERMAN, KELLY L (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:KELLERMAN
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 1:350 PEE DEE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-4932
Mailing Address - Country:US
Mailing Address - Phone:704-986-1500
Mailing Address - Fax:704-982-5279
Practice Address - Street 1:5700 EXECUTIVE CENTER DR
Practice Address - Street 2:SUITE 110
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-8858
Practice Address - Country:US
Practice Address - Phone:704-525-3255
Practice Address - Fax:704-525-0949
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0026901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical