Provider Demographics
NPI:1619290954
Name:MENDIOLA, KELLY L (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:MENDIOLA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 1/2 PRINCE AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-2450
Mailing Address - Country:US
Mailing Address - Phone:706-425-8900
Mailing Address - Fax:706-425-8600
Practice Address - Street 1:523 1/2 PRINCE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-2450
Practice Address - Country:US
Practice Address - Phone:706-425-8900
Practice Address - Fax:706-425-8600
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-01
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0042701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical