Provider Demographics
NPI:1750663662
Name:DAHLKE, KELLY (LMSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DAHLKE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4331 THURMOND TANNER RD
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30543
Mailing Address - Country:US
Mailing Address - Phone:678-513-5700
Mailing Address - Fax:678-513-5836
Practice Address - Street 1:4331 THURMOND TANNER RD
Practice Address - Street 2:
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30543
Practice Address - Country:US
Practice Address - Phone:678-513-5700
Practice Address - Fax:678-513-5836
Is Sole Proprietor?:No
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW005258101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor