Provider Demographics
NPI:1023505047
Name:KELLY, SELINA HARRISON (LCSW)
Entity type:Individual
Prefix:MS
First Name:SELINA
Middle Name:HARRISON
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 6605
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24068-6605
Mailing Address - Country:US
Mailing Address - Phone:540-944-4994
Mailing Address - Fax:540-944-6446
Practice Address - Street 1:930 CAMBRIA ST NE STE 100
Practice Address - Street 2:
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073-1631
Practice Address - Country:US
Practice Address - Phone:540-944-4994
Practice Address - Fax:540-944-6446
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-16
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040104531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1023505047Medicaid