Provider Demographics
NPI:1710462759
Name:SELTZER, KELLY (BAS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SELTZER
Suffix:
Gender:F
Credentials:BAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 MONTEREY CIR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-8242
Mailing Address - Country:US
Mailing Address - Phone:404-399-9077
Mailing Address - Fax:
Practice Address - Street 1:320 MONTEREY CIR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-8242
Practice Address - Country:US
Practice Address - Phone:404-399-9077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA21554587418Medicaid