Provider Demographics
NPI:1144496886
Name:KELLY, MARY CHARLENE (MSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CHARLENE
Last Name:KELLY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6657 BURGENFIELD DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-1800
Mailing Address - Country:US
Mailing Address - Phone:910-339-8856
Mailing Address - Fax:
Practice Address - Street 1:109 BRADFORD AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-5401
Practice Address - Country:US
Practice Address - Phone:910-323-0601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0042531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical