Provider Demographics
NPI:1861867236
Name:KELLY, JAVONNIA MULDROW (MA)
Entity Type:Individual
Prefix:
First Name:JAVONNIA
Middle Name:MULDROW
Last Name:KELLY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 N IRBY ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-2808
Mailing Address - Country:US
Mailing Address - Phone:843-667-9414
Mailing Address - Fax:843-667-1362
Practice Address - Street 1:360 N IRBY ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-2808
Practice Address - Country:US
Practice Address - Phone:843-667-9414
Practice Address - Fax:843-355-5616
Is Sole Proprietor?:No
Enumeration Date:2015-12-10
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6529101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC101YM0800XMedicaid