Provider Demographics
NPI:1518665215
Name:RHINES, KELLY GAIL
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:GAIL
Last Name:RHINES
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 1:1021 LINCOLN COURT AVE NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30329-1823
Mailing Address - Country:US
Mailing Address - Phone:909-560-4982
Mailing Address - Fax:
Practice Address - Street 1:1021 LINCOLN COURT AVE NE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-1823
Practice Address - Country:US
Practice Address - Phone:909-560-4982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-21
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT002008106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty