Provider Demographics
NPI:1962536300
Name:HENSON, KELLY CLEON (LCAS)
Entity type:Individual
Prefix:MR
First Name:KELLY
Middle Name:CLEON
Last Name:HENSON
Suffix:
Gender:M
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 KENTUCKY DR
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27527-6272
Mailing Address - Country:US
Mailing Address - Phone:919-740-8428
Mailing Address - Fax:919-243-1856
Practice Address - Street 1:3826 BLAND RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6239
Practice Address - Country:US
Practice Address - Phone:919-740-8428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC506101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6111836Medicaid