Healthcare Provider Details

I. General information

NPI: 1699483867
Provider Name (Legal Business Name): KELLY JUSTIN BUSHER LCSWA, PSS, QP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2022
Last Update Date: 03/08/2023
Certification Date: 03/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 S MAIN ST STE H
MOUNT HOLLY NC
28120-1618
US

IV. Provider business mailing address

205 S CLAY ST
LOWELL NC
28098-1811
US

V. Phone/Fax

Practice location:
  • Phone: 704-759-6525
  • Fax: 704-601-3470
Mailing address:
  • Phone: 704-778-2201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP018114
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: