Provider Demographics
NPI:1265421937
Name:LEWIS, KELLIE MCDOUGALL (LISW-CP, CAC-AD)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:MCDOUGALL
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LISW-CP, CAC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31447
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-0025
Mailing Address - Country:US
Mailing Address - Phone:843-273-0077
Mailing Address - Fax:843-273-0075
Practice Address - Street 1:9403 HIGHWAY 707 STE B
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-7758
Practice Address - Country:US
Practice Address - Phone:843-273-0077
Practice Address - Fax:843-273-0075
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC0396101YA0400X
SC101571041C0700X
MD144741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCC916OtherGROUP REAL COUNSELING LLC
SCSC1938C916OtherMEDICARE PTAN