Provider Demographics
NPI:1407217011
Name:KELLY, KANDIS (LCSWA)
Entity type:Individual
Prefix:
First Name:KANDIS
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 CARL SANDBURG CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-2049
Mailing Address - Country:US
Mailing Address - Phone:919-987-2792
Mailing Address - Fax:919-212-8581
Practice Address - Street 1:3401 CARL SANDBURG CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-2049
Practice Address - Country:US
Practice Address - Phone:919-987-2792
Practice Address - Fax:919-212-8581
Is Sole Proprietor?:No
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0096711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical