MEDICARE: KELLY ANNETTE ARCHER

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1790391035
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY ANNETTE ARCHER

Provider Business Mailing Address
First Line	:	190 CAMDEN HILL RD STE A
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30046-2448
Country	:	US
Telephone Number	:	770-513-8988
Fax Number	:	770-513-2565

Provider Business Practice Location Address
First Line	:	190 CAMDEN HILL RD STE A
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30046-2448
Country	:	US
Telephone Number	:	770-513-8988
Fax Number	:	770-513-2565

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

Provider Enumeration Date	:	09/22/2020
Last Update Date	:	09/22/2020

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