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NPI Code Detail

MEDICARE: KELLY L KELLERMAN LCSW

MEDICARE: KELLY L KELLERMAN 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
11041C0700XClinical Social WorkerC002690NC

General Provider Information

NPI Number : 1073534384
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY L KELLERMAN LCSW
Provider Business Mailing Address
First Line : 350 PEE DEE AVE
Second Line : SUITE 101
City : ALBEMARLE
State : NC
Zip : 28001-4932
Country : US
Telephone Number : 704-986-1500
Fax Number : 704-982-5279
Provider Business Practice Location Address
First Line : 5700 EXECUTIVE CENTER DR
Second Line : SUITE 110
City : CHARLOTTE
State : NC
Zip : 28212-8858
Country : US
Telephone Number : 704-525-3255
Fax Number : 704-525-0949
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/21/2006
Last Update Date : 03/13/2017

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