Provider Demographics
NPI:1891428462
Name:TERRELL, KELLY (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:TERRELL
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 GLENLAKE DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-2736
Mailing Address - Country:US
Mailing Address - Phone:678-689-5823
Mailing Address - Fax:
Practice Address - Street 1:3330 CHASTAIN MEADOWS PKWY NW STE 200
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-5881
Practice Address - Country:US
Practice Address - Phone:678-689-5823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst