Provider Demographics
NPI:1629355169
Name:FITZWATER, KELLY (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FITZWATER
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7820 CHELSEA JADE LN
Mailing Address - Street 2:APT 617
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-3533
Mailing Address - Country:US
Mailing Address - Phone:704-533-4110
Mailing Address - Fax:
Practice Address - Street 1:4601 PARK RD
Practice Address - Street 2:SUITE 400
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3239
Practice Address - Country:US
Practice Address - Phone:704-344-0491
Practice Address - Fax:704-344-0493
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-11
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0073651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical