Provider Demographics
NPI:1467054908
Name:KELLY, THOMASENA SANDERS (MA, LPCA, ADC)
Entity Type:Individual
Prefix:MRS
First Name:THOMASENA
Middle Name:SANDERS
Last Name:KELLY
Suffix:
Gender:F
Credentials:MA, LPCA, ADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 SOUTHPORT DR
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-7080
Mailing Address - Country:US
Mailing Address - Phone:843-345-3394
Mailing Address - Fax:
Practice Address - Street 1:764 SAINT ANDREWS BLVD
Practice Address - Street 2:CHARLESTON
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407
Practice Address - Country:US
Practice Address - Phone:843-405-1122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2023-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1808318101YA0400X
SC7962101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)