Provider Demographics
NPI:1447724224
Name:GUARENTE, KELLY COLLEEN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:COLLEEN
Last Name:GUARENTE
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:PO BOX 2567
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-2567
Mailing Address - Country:US
Mailing Address - Phone:706-842-5330
Mailing Address - Fax:706-842-5340
Practice Address - Street 1:8509 CROWN CRESCENT CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227-7733
Practice Address - Country:US
Practice Address - Phone:706-842-5330
Practice Address - Fax:706-842-5340
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1-21-48128103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst