MEDICARE: MS. QUINTISIA BERETE 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	101YP2500X	Professional Counselor	LPC015806	GA

General Provider Information

NPI Number	:	1790521649
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. QUINTISIA BERETE KELLY

Provider Business Mailing Address
First Line	:	203 BROWN THRASHER LN
Second Line	:
City	:	KATHLEEN
State	:	GA
Zip	:	31047-2746
Country	:	US
Telephone Number	:	803-260-5807
Fax Number	:

Provider Business Practice Location Address
First Line	:	2198 INGLESIDE AVE
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31204-2030
Country	:	US
Telephone Number	:	803-260-5807
Fax Number	:

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

Provider Enumeration Date	:	07/01/2024
Last Update Date	:	03/20/2026

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