Provider Demographics
NPI:1730457193
Name:KELLY, KIM J (LCAS)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:J
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5015
Mailing Address - Country:US
Mailing Address - Phone:252-412-1963
Mailing Address - Fax:
Practice Address - Street 1:200 S POLLOCK ST
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:NC
Practice Address - Zip Code:27576-3062
Practice Address - Country:US
Practice Address - Phone:919-965-6770
Practice Address - Fax:919-965-0196
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-13
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2526101YA0400X, 101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor