MEDICARE: ALYSIA KELLEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	16654	SC

General Provider Information

NPI Number	:	1053276873
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALYSIA KELLEY

Provider Business Mailing Address
First Line	:	3876 RENEE DR UNIT B
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-4108
Country	:	US
Telephone Number	:	843-504-9972
Fax Number	:

Provider Business Practice Location Address
First Line	:	3876 RENEE DR UNIT B
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-4108
Country	:	US
Telephone Number	:	843-504-9972
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/23/2025
Last Update Date	:	12/23/2025

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Directions to “ ALYSIA KELLEY ” Practice Location

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