Provider Demographics
NPI:1154666576
Name:KELLY, ERIC JAMES (LCSW)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:JAMES
Last Name:KELLY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 LAKE BOONE TRL
Mailing Address - Street 2:SUITE 150
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-2934
Mailing Address - Country:US
Mailing Address - Phone:919-210-2070
Mailing Address - Fax:
Practice Address - Street 1:3801 LAKE BOONE TRL
Practice Address - Street 2:SUITE 150
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-2934
Practice Address - Country:US
Practice Address - Phone:919-210-2070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0072381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical