Provider Demographics
NPI:1891530523
Name:FAKHOURY, KELSEY KAREM
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:KAREM
Last Name:FAKHOURY
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 1:624 US HIGHWAY 17 S
Mailing Address - Street 2:
Mailing Address - City:HOLLY RIDGE
Mailing Address - State:NC
Mailing Address - Zip Code:28445-8660
Mailing Address - Country:US
Mailing Address - Phone:910-599-2230
Mailing Address - Fax:
Practice Address - Street 1:624 US HIGHWAY 17 S
Practice Address - Street 2:
Practice Address - City:HOLLY RIDGE
Practice Address - State:NC
Practice Address - Zip Code:28445-8660
Practice Address - Country:US
Practice Address - Phone:910-599-2230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCBACB1128242106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician