Provider Demographics
NPI:1134890429
Name:KELLY, KATHRYN CAROLINE (LCMHC, LCAS, NCC)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:CAROLINE
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCMHC, LCAS, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4030 WAKE FOREST RD STE 349
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-0010
Mailing Address - Country:US
Mailing Address - Phone:910-960-7398
Mailing Address - Fax:855-595-2573
Practice Address - Street 1:4030 WAKE FOREST RD STE 349
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-0010
Practice Address - Country:US
Practice Address - Phone:910-960-7398
Practice Address - Fax:855-595-2573
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-26
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-22979101YA0400X
NC11759101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)