Provider Demographics
NPI:1558700385
Name:LEWIS, KELLY DANIELS (MED, LPC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:DANIELS
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 411832
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28241-1832
Mailing Address - Country:US
Mailing Address - Phone:803-463-0643
Mailing Address - Fax:
Practice Address - Street 1:2106 CELANESE RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1306
Practice Address - Country:US
Practice Address - Phone:803-463-0643
Practice Address - Fax:803-324-5111
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-14
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5355101YP2500X
101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool