Provider Demographics
NPI:1083738777
Name:KNICK, KELSI ALYSSA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KELSI
Middle Name:ALYSSA
Last Name:KNICK
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 1:2525 VALLEY HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27603-3303
Mailing Address - Country:US
Mailing Address - Phone:919-602-1034
Mailing Address - Fax:
Practice Address - Street 1:3948 BROWNING PL
Practice Address - Street 2:SUITE 200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6510
Practice Address - Country:US
Practice Address - Phone:919-782-8730
Practice Address - Fax:919-872-8731
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0054291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106486Medicaid