Provider Demographics
NPI:1881788586
Name:WIENER, KELLY ALICIA (MA, LCMHC)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ALICIA
Last Name:WIENER
Suffix:
Gender:F
Credentials:MA, LCMHC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LCMHC
Mailing Address - Street 1:467 LAUREL BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:VILAS
Mailing Address - State:NC
Mailing Address - Zip Code:28692-9152
Mailing Address - Country:US
Mailing Address - Phone:919-815-1382
Mailing Address - Fax:
Practice Address - Street 1:467 LAUREL BRANCH RD
Practice Address - Street 2:
Practice Address - City:VILAS
Practice Address - State:NC
Practice Address - Zip Code:28692-9152
Practice Address - Country:US
Practice Address - Phone:919-815-1382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3873101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102318Medicaid