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General NPI Number Information
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NPI Number | 1538947098
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Entity Type | Individual
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Provider Name | CANDACE C. KELLY LMSW
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Gender | Female
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Dates
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Enumeration Date | 09/18/2023
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Last Update Date | 09/18/2023
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Provider Practice Location Address
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Address Line | 152 WACCAMAW MEDICAL PARK DR
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City | CONWAY
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State | SC
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Zip | 29526-8901
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Country | US
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Telephone | 910-520-8796
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Fax |
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Provider Business Mailing Address
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Address Line | 204 N SHORE DR UNIT 805
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City | MYRTLE BEACH
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State | SC
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Zip | 29579-4418
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Country | US
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Telephone | 910-520-8796
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | SW15978
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License Number State | SC
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