Provider Demographics
NPI:1285212159
Name:KELLY, KENNETH D (MA, LPC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:D
Last Name:KELLY
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2309 DEVINE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29205-2422
Mailing Address - Country:US
Mailing Address - Phone:803-250-1947
Mailing Address - Fax:
Practice Address - Street 1:2309 DEVINE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29205-2422
Practice Address - Country:US
Practice Address - Phone:803-250-1947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-31
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7756101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
3857OtherNO INSURANCE