MEDICARE: KELLY MARIE WASSON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	C012739	NC

General Provider Information

NPI Number	:	1063921161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY MARIE WASSON LCSW

Provider Business Mailing Address
First Line	:	2101 PETERS CREEK PKWY STE 16-19
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27127-3726
Country	:	US
Telephone Number	:	336-955-1379
Fax Number	:	704-939-1173

Provider Business Practice Location Address
First Line	:	2101 PETERS CREEK PKWY STE 16-19
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27127-3726
Country	:	US
Telephone Number	:	336-955-1379
Fax Number	:	704-939-1173

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2017
Last Update Date	:	11/23/2021

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