Provider Demographics
NPI:1295366169
Name:WOLFE, KELLY R
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:WOLFE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 OLDE HERITAGE WAY
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-6121
Mailing Address - Country:US
Mailing Address - Phone:717-669-0484
Mailing Address - Fax:
Practice Address - Street 1:4595 TOWNE LAKE PKWY STE 250
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-5514
Practice Address - Country:US
Practice Address - Phone:717-478-8486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006542101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health