Healthcare Provider Details

I. General information

NPI: 1275256836
Provider Name (Legal Business Name): KELLY RHYNE CAMPODONICO LCSW, MDIV
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY RHYNE LCSW, MDIV

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 06/27/2026
Certification Date: 06/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1954 AIRPORT RD STE 232
ATLANTA GA
30341-4956
US

IV. Provider business mailing address

1954 AIRPORT RD STE 232
ATLANTA GA
30341-4956
US

V. Phone/Fax

Practice location:
  • Phone: 404-563-5381
  • Fax: 404-500-0483
Mailing address:
  • Phone: 404-563-5381
  • Fax: 404-500-0483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberCSW010421
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License NumberCSW010421
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW010421
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: