Provider Demographics
NPI:1366420192
Name:KELLY, SUZANNE AUTREY (LPC,LCAS,CEAP,LEAP)
Entity type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:AUTREY
Last Name:KELLY
Suffix:
Gender:F
Credentials:LPC,LCAS,CEAP,LEAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:YADKINVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27055-5752
Mailing Address - Country:US
Mailing Address - Phone:336-466-1053
Mailing Address - Fax:336-677-1359
Practice Address - Street 1:110 W ELM ST
Practice Address - Street 2:
Practice Address - City:YADKINVILLE
Practice Address - State:NC
Practice Address - Zip Code:27055-1758
Practice Address - Country:US
Practice Address - Phone:336-677-3991
Practice Address - Fax:336-677-1359
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC60101Y00000X
NC1223101YA0400X
NC1070101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6112226Medicaid
NC1005HOtherBCBS OF NORTH CAROLINA