Provider Demographics
NPI:1982002119
Name:MASSENGALE, KELLEY (LCSW-BACS)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:MASSENGALE
Suffix:
Gender:F
Credentials:LCSW-BACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3428 LIME ST
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA
Mailing Address - State:AL
Mailing Address - Zip Code:35242-6340
Mailing Address - Country:US
Mailing Address - Phone:225-326-9490
Mailing Address - Fax:
Practice Address - Street 1:3428 LIME ST
Practice Address - Street 2:
Practice Address - City:VESTAVIA
Practice Address - State:AL
Practice Address - Zip Code:35242-6340
Practice Address - Country:US
Practice Address - Phone:225-326-9490
Practice Address - Fax:225-293-2912
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-22
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5046C1041C0700X
LA101681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical