=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225743149
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KALEN KELLY LISW-CP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2023
-----------------------------------------------------
Last Update Date | 05/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 61 RIVERWALK BLVD STE H
-----------------------------------------------------
City | RIDGELAND
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29936-3252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-636-5017
-----------------------------------------------------
Fax | 843-206-0256
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 61 RIVERWALK BLVD STE H
-----------------------------------------------------
City | RIDGELAND
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29936-3252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-636-5017
-----------------------------------------------------
Fax | 843-206-0256
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 16942
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------