Provider Demographics
NPI:1083977870
Name:SHOOK, KELLY MILLER (CSAC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MILLER
Last Name:SHOOK
Suffix:
Gender:F
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1149
Mailing Address - Street 2:
Mailing Address - City:NEBO
Mailing Address - State:NC
Mailing Address - Zip Code:28761-0964
Mailing Address - Country:US
Mailing Address - Phone:828-659-3418
Mailing Address - Fax:828-659-3291
Practice Address - Street 1:1251 PINNACLE CHURCH ROAD
Practice Address - Street 2:
Practice Address - City:NEBO
Practice Address - State:NC
Practice Address - Zip Code:28761-5753
Practice Address - Country:US
Practice Address - Phone:828-659-3418
Practice Address - Fax:828-659-3291
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2816101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)