Provider Demographics
NPI:1407492028
Name:FREEMAN, KELLY (RBT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:FREEMAN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 N GENERALS BLVD
Mailing Address - Street 2:
Mailing Address - City:LINCOLNTON
Mailing Address - State:NC
Mailing Address - Zip Code:28092-3500
Mailing Address - Country:US
Mailing Address - Phone:704-748-0616
Mailing Address - Fax:704-240-9980
Practice Address - Street 1:518 N GENERALS BLVD
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-3500
Practice Address - Country:US
Practice Address - Phone:704-748-0616
Practice Address - Fax:704-240-9980
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC56-1677267Medicaid