Provider Demographics
NPI:1720473234
Name:WELCH, CALISSA NICOLE (LCSW)
Entity Type:Individual
Prefix:
First Name:CALISSA
Middle Name:NICOLE
Last Name:WELCH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12141 OLD DULIN FARMS WAY
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-5208
Mailing Address - Country:US
Mailing Address - Phone:860-778-5317
Mailing Address - Fax:
Practice Address - Street 1:12141 OLD DULIN FARMS WAY
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-5208
Practice Address - Country:US
Practice Address - Phone:860-778-5317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-01
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8929101YM0800X, 1041C0700X
NCC0146861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health