Basic Information
| Provider Information | |||||||||
| NPI: | 1134537657 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | ERWIN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 AUBURN DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283069353 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2212 HOPE MILLS RD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107790454 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2014 | ||||||||
| LastUpdateDate: | 05/25/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 10991 | NC | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 10991 | NC | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 10991 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.