MEDICARE: LETISHAL KELLY

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1194204990
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LETISHAL KELLY

Provider Business Mailing Address
First Line	:	10810 TRADITION VIEW DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-1421
Country	:	US
Telephone Number	:	704-493-0466
Fax Number	:

Provider Business Practice Location Address
First Line	:	106 YORK ST
Second Line	:
City	:	CHESTER
State	:	SC
Zip	:	29706-1484
Country	:	US
Telephone Number	:	704-493-0466
Fax Number	:

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

Provider Enumeration Date	:	08/13/2018
Last Update Date	:	08/13/2018

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Directions to “ LETISHAL KELLY ” Practice Location

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