MEDICARE: ELIZABETH KELLY LPC

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	101YP2500X	Professional Counselor	0701008804	VA

General Provider Information

NPI Number	:	1063059434
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH KELLY LPC

Provider Business Mailing Address
First Line	:	8109 SADDLE CREST DR
Second Line	:
City	:	MECHANICSVILLE
State	:	VA
Zip	:	23111-2261
Country	:	US
Telephone Number	:	804-519-0821
Fax Number	:

Provider Business Practice Location Address
First Line	:	10611 PATTERSON AVE
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23238-4733
Country	:	US
Telephone Number	:	804-912-2947
Fax Number	:

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

Provider Enumeration Date	:	12/04/2019
Last Update Date	:	12/04/2019

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