Provider Demographics
NPI:1770830663
Name:VOLSON, KELISA
Entity Type:Individual
Prefix:
First Name:KELISA
Middle Name:
Last Name:VOLSON
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 1:120 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-4663
Mailing Address - Country:US
Mailing Address - Phone:678-216-7519
Mailing Address - Fax:
Practice Address - Street 1:126 W SOLOMON ST STE 4
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-3045
Practice Address - Country:US
Practice Address - Phone:678-224-7404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC005779101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional