Provider Demographics
NPI:1861166381
Name:BALLENTINE, KELSIE ELIZABETH (MS)
Entity type:Individual
Prefix:
First Name:KELSIE
Middle Name:ELIZABETH
Last Name:BALLENTINE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17714 KINGS POINT DR STE B
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-6929
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17714 KINGS POINT DR STE B
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-6929
Practice Address - Country:US
Practice Address - Phone:704-997-5397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-07
Last Update Date:2021-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12325A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist