Provider Demographics
NPI:1124238530
Name:CARPENTER, KELLY L (LCSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:CARPENTER
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:PO BOX 391
Mailing Address - Street 2:
Mailing Address - City:MC ADENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28101-0391
Mailing Address - Country:US
Mailing Address - Phone:704-228-9289
Mailing Address - Fax:
Practice Address - Street 1:1010 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NC
Practice Address - Zip Code:28120-2021
Practice Address - Country:US
Practice Address - Phone:704-228-9289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0044881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC146AYOtherBCBS OF NC
NC2852061Medicare PIN