Provider Demographics
NPI:1881786945
Name:PICKELL, KELLY BROADWATER (MA, LPA, LPC, CEDS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:BROADWATER
Last Name:PICKELL
Suffix:
Gender:F
Credentials:MA, LPA, LPC, CEDS
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:BROADWATER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, LPA, LPC, CEDS
Mailing Address - Street 1:3240 BURNT MILL DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-2576
Mailing Address - Country:US
Mailing Address - Phone:910-790-9500
Mailing Address - Fax:910-796-8111
Practice Address - Street 1:3240 BURNT MILL DR
Practice Address - Street 2:SUITE 1
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2576
Practice Address - Country:US
Practice Address - Phone:910-790-9500
Practice Address - Fax:910-796-8111
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2481103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC046XAOtherBCBS
NC046XAOtherBCBS