Provider Demographics
NPI:1629794755
Name:CALLAHAN, KELLY LYNN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:CALLAHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3206 ASHWELL OAKS LN
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-1213
Mailing Address - Country:US
Mailing Address - Phone:904-614-5780
Mailing Address - Fax:
Practice Address - Street 1:10430 HARRIS OAK BLVD STE L
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-7513
Practice Address - Country:US
Practice Address - Phone:704-360-3637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-19
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0152491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical