Provider Demographics
NPI:1215297601
Name:STEVENSON, KELLY R (LCSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:STEVENSON
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 1:2131 WESLEY CT
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-2453
Mailing Address - Country:US
Mailing Address - Phone:850-459-6961
Mailing Address - Fax:229-225-4374
Practice Address - Street 1:1102 SMITH AVE
Practice Address - Street 2:SUITE K
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5739
Practice Address - Country:US
Practice Address - Phone:229-227-2429
Practice Address - Fax:229-225-4374
Is Sole Proprietor?:No
Enumeration Date:2012-05-21
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW105501041C0700X
GACSW0046221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical