Provider Demographics
NPI:1386495372
Name:WOODBURN, KELLY (LPC-MHSP (T))
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WOODBURN
Suffix:
Gender:F
Credentials:LPC-MHSP (T)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10261 KINGSTON PIKE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-3276
Mailing Address - Country:US
Mailing Address - Phone:865-283-1777
Mailing Address - Fax:
Practice Address - Street 1:10261 KINGSTON PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-3276
Practice Address - Country:US
Practice Address - Phone:865-283-1777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6390101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health