Healthcare Provider Details

I. General information

NPI: 1568390961
Provider Name (Legal Business Name): KELLI ALISE CRUSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6918 SHALLOWFORD RD STE 326
CHATTANOOGA TN
37421-1553
US

IV. Provider business mailing address

736 CARROL DR
RINGGOLD GA
30736-8452
US

V. Phone/Fax

Practice location:
  • Phone: 423-827-7695
  • Fax:
Mailing address:
  • Phone: 423-888-2122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16089
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: