Provider Demographics
NPI:1508500505
Name:KELLEY, CAROL A
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:KELLEY
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 1:5969 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT JACKSON
Mailing Address - State:VA
Mailing Address - Zip Code:22842-9302
Mailing Address - Country:US
Mailing Address - Phone:802-236-5945
Mailing Address - Fax:
Practice Address - Street 1:5969 BROAD ST
Practice Address - Street 2:
Practice Address - City:MOUNT JACKSON
Practice Address - State:VA
Practice Address - Zip Code:22842-9302
Practice Address - Country:US
Practice Address - Phone:802-236-5945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040103461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical