Provider Demographics
NPI:1063921161
Name:WASSON, KELLY MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:WASSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 PETERS CREEK PKWY STE 16-19
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-3726
Mailing Address - Country:US
Mailing Address - Phone:336-955-1379
Mailing Address - Fax:704-939-1173
Practice Address - Street 1:2101 PETERS CREEK PKWY STE 16-19
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-3726
Practice Address - Country:US
Practice Address - Phone:336-955-1379
Practice Address - Fax:704-939-1173
Is Sole Proprietor?:No
Enumeration Date:2017-09-21
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0127391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical