Provider Demographics
NPI:1790521649
Name:KELLY, QUINTISIA BERETE
Entity type:Individual
Prefix:MS
First Name:QUINTISIA
Middle Name:BERETE
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 BROWN THRASHER LN
Mailing Address - Street 2:
Mailing Address - City:KATHLEEN
Mailing Address - State:GA
Mailing Address - Zip Code:31047-2746
Mailing Address - Country:US
Mailing Address - Phone:803-260-5807
Mailing Address - Fax:
Practice Address - Street 1:404 CORDER RD STE 300
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-7195
Practice Address - Country:US
Practice Address - Phone:803-260-5807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA009307101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health