Healthcare Provider Details

I. General information

NPI: 1871661561
Provider Name (Legal Business Name): KELLI STEWART MSW, LCSW, MDIV
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 WAGONER DR STE 319
FAYETTEVILLE NC
28303-4671
US

IV. Provider business mailing address

1200 S HORNER BLVD 1371
SANFORD NC
27331-5709
US

V. Phone/Fax

Practice location:
  • Phone: 919-721-8602
  • Fax:
Mailing address:
  • Phone: 919-721-8602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC007077
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC007077
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: