Provider Demographics
NPI:1609570548
Name:KELLY, KENDERLIN JOVAN (LCAS)
Entity Type:Individual
Prefix:MRS
First Name:KENDERLIN
Middle Name:JOVAN
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 PERSON ST STE 103
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-5886
Mailing Address - Country:US
Mailing Address - Phone:910-483-0958
Mailing Address - Fax:
Practice Address - Street 1:418 PERSON ST STE 103
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-5886
Practice Address - Country:US
Practice Address - Phone:910-483-0958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty