Healthcare Provider Details

I. General information

NPI: 1205242021
Provider Name (Legal Business Name): KELLI HAAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 DEN-MAC DR
BOONE NC
28607-6543
US

IV. Provider business mailing address

515 CLANTON RD
CHARLOTTE NC
28217-1309
US

V. Phone/Fax

Practice location:
  • Phone: 828-263-8171
  • Fax: 828-263-0995
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2898
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: