Provider Demographics
NPI:1407822372
Name:KELLY, KATHERINE T (PHD)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:T
Last Name:KELLY
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 1:148 CARRISBROOKE LN
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-2528
Mailing Address - Country:US
Mailing Address - Phone:336-406-8431
Mailing Address - Fax:336-732-1411
Practice Address - Street 1:1001 REYNOLDA RD
Practice Address - Street 2:STOCKTON COTTAGE
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-3245
Practice Address - Country:US
Practice Address - Phone:336-723-1011
Practice Address - Fax:336-723-1411
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2729103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical