Provider Demographics
NPI:1225743149
Name:KELLY, KALEN (LISW-CP)
Entity type:Individual
Prefix:
First Name:KALEN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 RIVERWALK BLVD STE H
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:SC
Mailing Address - Zip Code:29936-3252
Mailing Address - Country:US
Mailing Address - Phone:843-636-5017
Mailing Address - Fax:843-206-0256
Practice Address - Street 1:61 RIVERWALK BLVD STE H
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:SC
Practice Address - Zip Code:29936-3252
Practice Address - Country:US
Practice Address - Phone:843-636-5017
Practice Address - Fax:843-206-0256
Is Sole Proprietor?:No
Enumeration Date:2023-01-16
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC169421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical