Provider Demographics
NPI:1568722825
Name:SERRICCHIO, KELLY HOWARD (LISW-CP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:HOWARD
Last Name:SERRICCHIO
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-2410
Mailing Address - Country:US
Mailing Address - Phone:864-467-3783
Mailing Address - Fax:
Practice Address - Street 1:30 POINTE CIR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3506
Practice Address - Country:US
Practice Address - Phone:864-655-5193
Practice Address - Fax:864-655-5183
Is Sole Proprietor?:No
Enumeration Date:2012-05-21
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC168751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical