Provider Demographics
NPI:1699595793
Name:KELLY, MADELINE
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 ELMORE RD
Mailing Address - Street 2:
Mailing Address - City:BISHOPVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29010-7729
Mailing Address - Country:US
Mailing Address - Phone:803-229-5681
Mailing Address - Fax:
Practice Address - Street 1:1451 RETAIL ROW
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-4258
Practice Address - Country:US
Practice Address - Phone:800-805-6989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)