Provider Demographics
NPI:1578183745
Name:KELLY, MICHAELA MARY (LMHC, LPC)
Entity Type:Individual
Prefix:DR
First Name:MICHAELA
Middle Name:MARY
Last Name:KELLY
Suffix:
Gender:F
Credentials:LMHC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 WILLOW WOOD LN APT 104
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29730-6692
Mailing Address - Country:US
Mailing Address - Phone:407-963-0510
Mailing Address - Fax:
Practice Address - Street 1:815 WILLOW WOOD LN APT 104
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-6692
Practice Address - Country:US
Practice Address - Phone:407-963-0510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-17
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH11664101YM0800X
SC6542101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health