Provider Demographics
NPI:1972090538
Name:SPROLES, KELLEY DYANNE
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:DYANNE
Last Name:SPROLES
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 1:5480 MCGINNIS VILLAGE PL STE 104
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-1746
Mailing Address - Country:US
Mailing Address - Phone:678-213-2194
Mailing Address - Fax:678-922-7767
Practice Address - Street 1:5480 MCGINNIS VILLAGE PL STE 104
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-1746
Practice Address - Country:US
Practice Address - Phone:678-213-2194
Practice Address - Fax:678-922-7767
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-19
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
GAMFT001763106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist