Provider Demographics
NPI:1720557309
Name:CIANCIOLO, KELLY MARGARET MACE (LPC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARGARET MACE
Last Name:CIANCIOLO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1977 CAMELLIA DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-5205
Mailing Address - Country:US
Mailing Address - Phone:504-295-9312
Mailing Address - Fax:
Practice Address - Street 1:209B SWANTON WAY STE 204
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3271
Practice Address - Country:US
Practice Address - Phone:504-295-9312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006660101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health