Provider Demographics
NPI:1255723912
Name:CASSELL, KELLY RENEE (LPC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RENEE
Last Name:CASSELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:RENEE
Other - Last Name:WOLIVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7054 W BLUE GRASS TRL
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:VA
Mailing Address - Zip Code:24318-3456
Mailing Address - Country:US
Mailing Address - Phone:276-613-1730
Mailing Address - Fax:
Practice Address - Street 1:540 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-2209
Practice Address - Country:US
Practice Address - Phone:276-223-3291
Practice Address - Fax:276-223-3249
Is Sole Proprietor?:No
Enumeration Date:2015-03-04
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006065101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional