Provider Demographics
NPI:1366075491
Name:POEHAILOS, KELLY MARIE (LPCA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:POEHAILOS
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 SLANE RD
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-9187
Mailing Address - Country:US
Mailing Address - Phone:336-408-8161
Mailing Address - Fax:
Practice Address - Street 1:6614 SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27023-9303
Practice Address - Country:US
Practice Address - Phone:336-945-0137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15218101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health