Provider Demographics
NPI:1306515630
Name:GILLETTE, KELLY ANNE (LPC/MHSP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:GILLETTE
Suffix:
Gender:F
Credentials:LPC/MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3122 ORCHARD AVE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37917-2943
Mailing Address - Country:US
Mailing Address - Phone:248-342-3203
Mailing Address - Fax:
Practice Address - Street 1:111 CENTER PARK DR STE 1300
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-2124
Practice Address - Country:US
Practice Address - Phone:248-342-3203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5591101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health