{
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"OrgName": "KELLY LUCE ACEVEDO",
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"FirstLineMailingAddress": "117 HOLLY SPRINGS DR",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "PEACHTREE CITY",
"MailingAddressStateName": "GA",
"MailingAddressPostalCode": "30269-3045",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "470-296-1841",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "111 PETROL PT",
"SecondLinePracticeLocationAddress": "SUITE H",
"PracticeLocationAddressCityName": "PEACHTREE CITY",
"PracticeLocationAddressStateName": "GA",
"PracticeLocationAddressPostalCode": "30269-1550",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "470-296-1841",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "11/26/2013",
"LastUpdateDate": "11/26/2013",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "ACEVEDO",
"AuthorizedOfficialFirstName": "KELLY",
"AuthorizedOfficialMiddleName": "LUCE",
"AuthorizedOfficialTitle": "LICENSED MASTER SOCIAL WORKER",
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"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "LMSW",
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"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "104100000X",
"TaxonomyName": "Social Worker",
"LicenseNumber": "MSW005370",
"LicenseNumberStateCode": "GA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}