MEDICARE: KELLY SANDERS DUSEK LPC, LCMHC

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	101YP2500X	Professional Counselor	7006	SC
2	101YS0200X	School Counselor		NC
3	101YS0200X	School Counselor		SC
4	101YM0800X	Mental Health Counselor	19794	NC

General Provider Information

NPI Number	:	1952966681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY SANDERS DUSEK LPC, LCMHC

Provider Business Mailing Address
First Line	:	15812 WALNUT HILL DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28278-5010
Country	:	US
Telephone Number	:	704-641-3824
Fax Number	:

Provider Business Practice Location Address
First Line	:	15812 WALNUT HILL DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28278-5010
Country	:	US
Telephone Number	:	803-542-9680
Fax Number	:

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

Provider Enumeration Date	:	05/08/2019
Last Update Date	:	03/04/2025

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