MEDICARE: LISA DANIELLE KELLEY 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	003314	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750454328
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA DANIELLE KELLEY LCSW

Provider Business Mailing Address
First Line	:	5400 LAUREL SPRINGS PKWY
Second Line	:	SUITE 1101
City	:	SUWANEE
State	:	GA
Zip	:	30024-6056
Country	:	US
Telephone Number	:	678-908-5543
Fax Number	:

Provider Business Practice Location Address
First Line	:	5400 LAUREL SPRINGS PKWY
Second Line	:	SUITE 1101
City	:	SUWANEE
State	:	GA
Zip	:	30024-6056
Country	:	US
Telephone Number	:	678-908-5543
Fax Number	:

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

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	04/29/2008

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