Provider Demographics
NPI:1568158764
Name:CLEMENTE, KELLY NICOLE (LPCC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:NICOLE
Last Name:CLEMENTE
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6233 KELLOGG DR
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3124
Mailing Address - Country:US
Mailing Address - Phone:571-332-2167
Mailing Address - Fax:
Practice Address - Street 1:6233 KELLOGG DR
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3124
Practice Address - Country:US
Practice Address - Phone:571-332-2167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0019849101YP2500X
VA0704013947101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional