=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851979975
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY JURAE BANKS BROWN PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2021
-----------------------------------------------------
Last Update Date | 04/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 VILLAGE TRACE NE BLDG 23, SUITE 100
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-971-3303
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4611 RIVER HILL CIR
-----------------------------------------------------
City | ELLENWOOD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30294-1884
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-920-1151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY004757
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------