Healthcare Provider Details

I. General information

NPI: 1366420192
Provider Name (Legal Business Name): SUZANNE AUTREY KELLY LPC,LCAS,CEAP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 W ELM ST
YADKINVILLE NC
27055-1758
US

IV. Provider business mailing address

110 W ELM ST # 1758
YADKINVILLE NC
27055-8203
US

V. Phone/Fax

Practice location:
  • Phone: 336-677-3991
  • Fax: 336-677-1359
Mailing address:
  • Phone: 336-466-1053
  • Fax: 336-677-1359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number60
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1223
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1070
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: