Provider Demographics
NPI:1053875021
Name:SINK, KELLY M (LPCA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:SINK
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:PO BOX 1083
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27023-1083
Mailing Address - Country:US
Mailing Address - Phone:336-291-7477
Mailing Address - Fax:336-217-8044
Practice Address - Street 1:2499 HENNING DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-4558
Practice Address - Country:US
Practice Address - Phone:336-291-7477
Practice Address - Fax:336-217-8044
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA14504101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty