Provider Demographics
NPI:1871047720
Name:KELLY, BREANNA (LCSW)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4026 BIRCHWOOD CV
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-5251
Mailing Address - Country:US
Mailing Address - Phone:813-361-0596
Mailing Address - Fax:
Practice Address - Street 1:4026 BIRCHWOOD CV
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-5251
Practice Address - Country:US
Practice Address - Phone:813-361-0596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0059551041C0700X
11833409103K00000X
GAMSW006385104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker