Provider Demographics
NPI:1871661561
Name:STEWART, KELLI (MSW, LCSW, MDIV)
Entity Type:Individual
Prefix:MS
First Name:KELLI
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:MSW, LCSW, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 S HORNER BLVD
Mailing Address - Street 2:1371
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27331-5709
Mailing Address - Country:US
Mailing Address - Phone:919-721-8602
Mailing Address - Fax:
Practice Address - Street 1:351 WAGONER DR STE 319
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-4671
Practice Address - Country:US
Practice Address - Phone:919-721-8602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC007077101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional