Healthcare Provider Details

I. General information

NPI: 1255564985
Provider Name (Legal Business Name): KELLY PRITCHETT RODRIGUES LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2009
Last Update Date: 01/03/2022
Certification Date: 01/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MARIAH CIR APT E18
BEECH MOUNTAIN NC
28604-6830
US

IV. Provider business mailing address

PO BOX 2253
BANNER ELK NC
28604-2253
US

V. Phone/Fax

Practice location:
  • Phone: 336-688-3784
  • Fax:
Mailing address:
  • Phone: 336-688-3784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7441
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF 63488
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7441
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: