Healthcare Provider Details

I. General information

NPI: 1407822372
Provider Name (Legal Business Name): KATHERINE T. KELLY PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 REYNOLDA RD STOCKTON COTTAGE
WINSTON-SALEM NC
27104-3245
US

IV. Provider business mailing address

148 CARRISBROOKE LN
WINSTON-SALEM NC
27104-2528
US

V. Phone/Fax

Practice location:
  • Phone: 336-723-1011
  • Fax: 336-723-1411
Mailing address:
  • Phone: 336-406-8431
  • Fax: 336-732-1411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2729
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: