Provider Demographics
NPI:1578708251
Name:EDWARDS, KELLIE M (PHD)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:M
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 LAKE FORREST DR NW
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-3824
Mailing Address - Country:US
Mailing Address - Phone:404-256-9325
Mailing Address - Fax:404-256-3662
Practice Address - Street 1:6000 LAKE FORREST DR NW
Practice Address - Street 2:SUITE 103
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-3824
Practice Address - Country:US
Practice Address - Phone:404-256-9325
Practice Address - Fax:404-256-3662
Is Sole Proprietor?:No
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3224103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical