MEDICARE: KELLY O'BRIEN MCKENNA LCSWA, MSW

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	P020956	NC

General Provider Information

NPI Number	:	1235976283
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY O'BRIEN MCKENNA LCSWA, MSW

Provider Business Mailing Address
First Line	:	901 BATTLEGROUND AVE STE B
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27408-2107
Country	:	US
Telephone Number	:	336-337-5469
Fax Number	:	336-660-2563

Provider Business Practice Location Address
First Line	:	1611 E FRANKLIN ST
Second Line	:
City	:	CHAPEL HILL
State	:	NC
Zip	:	27514-2888
Country	:	US
Telephone Number	:	415-254-6239
Fax Number	:

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

Provider Enumeration Date	:	07/09/2024
Last Update Date	:	07/09/2024

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