=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205266368
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KELLY LUCE ACEVEDO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2013
-----------------------------------------------------
Last Update Date | 11/26/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 PETROL PT SUITE H
-----------------------------------------------------
City | PEACHTREE CITY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30269-1550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-296-1841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 117 HOLLY SPRINGS DR
-----------------------------------------------------
City | PEACHTREE CITY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30269-3045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-296-1841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED MASTER SOCIAL WORKER
-----------------------------------------------------
Name | KELLY LUCE ACEVEDO
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 470-296-1841
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | MSW005370
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------