Provider Demographics
NPI:1689815722
Name:KELLY, BRIANA MARIE
Entity Type:Individual
Prefix:
First Name:BRIANA
Middle Name:MARIE
Last Name:KELLY
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 1:308 GROVEDIERE LN
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-2208
Mailing Address - Country:US
Mailing Address - Phone:910-431-6418
Mailing Address - Fax:910-270-0270
Practice Address - Street 1:308 GROVEDIERE LN
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:NC
Practice Address - Zip Code:28443-2208
Practice Address - Country:US
Practice Address - Phone:910-431-6418
Practice Address - Fax:910-270-0270
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-19
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health