Provider Demographics
NPI:1194829572
Name:GWALTNEY, KELLIE (MA, LMFT, LPC)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:GWALTNEY
Suffix:
Gender:F
Credentials:MA, LMFT, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 OLD ALABAMA RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30022-8593
Mailing Address - Country:US
Mailing Address - Phone:678-893-5300
Mailing Address - Fax:678-893-5312
Practice Address - Street 1:2750 OLD ALABAMA RD
Practice Address - Street 2:SUITE 200
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30022-8593
Practice Address - Country:US
Practice Address - Phone:678-893-5300
Practice Address - Fax:678-893-5312
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008494101YP2500X
GAMFT001506106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional