Healthcare Provider Details

I. General information

NPI: 1083738777
Provider Name (Legal Business Name): KELSI ALYSSA KNICK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3948 BROWNING PL SUITE 200
RALEIGH NC
27609-6510
US

IV. Provider business mailing address

2525 VALLEY HAVEN DR
RALEIGH NC
27603-3303
US

V. Phone/Fax

Practice location:
  • Phone: 919-782-8730
  • Fax: 919-872-8731
Mailing address:
  • Phone: 919-602-1034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC005429
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: