Provider Demographics
NPI:1386979763
Name:KELLY, REGINA CASSANDRA (LCSW)
Entity type:Individual
Prefix:MS
First Name:REGINA
Middle Name:CASSANDRA
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1023 FAIRFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-6607
Mailing Address - Country:US
Mailing Address - Phone:910-550-3803
Mailing Address - Fax:910-550-3803
Practice Address - Street 1:803 STAMPER RD STE G
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-4193
Practice Address - Country:US
Practice Address - Phone:910-261-5941
Practice Address - Fax:910-550-3803
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-02
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0065341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005589Medicaid