Provider Demographics
NPI:1851444525
Name:MCKENDREE, KELLYE JANE GIST (MA, LPC)
Entity Type:Individual
Prefix:MS
First Name:KELLYE
Middle Name:JANE GIST
Last Name:MCKENDREE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 ANDERSONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-7976
Mailing Address - Country:US
Mailing Address - Phone:919-417-1896
Mailing Address - Fax:
Practice Address - Street 1:1021 ANDERSONWOOD DR
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-7976
Practice Address - Country:US
Practice Address - Phone:919-417-1896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3961101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102920Medicaid