Provider Demographics
NPI:1386727048
Name:RAY, KELLE CHANDLER (PHD)
Entity type:Individual
Prefix:DR
First Name:KELLE
Middle Name:CHANDLER
Last Name:RAY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 HERRINGTON RD
Mailing Address - Street 2:BUILDING 2
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5649
Mailing Address - Country:US
Mailing Address - Phone:770-962-1944
Mailing Address - Fax:770-962-1886
Practice Address - Street 1:1805 HERRINGTON RD
Practice Address - Street 2:BUILDING 2
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5649
Practice Address - Country:US
Practice Address - Phone:770-962-1944
Practice Address - Fax:770-962-1886
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1811103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00615557AMedicaid
GA00615557AMedicaid
GA68BBFDLMedicare ID - Type Unspecified