Provider Demographics
NPI:1679335384
Name:KELLY, CORLETTE GANTT (LPC)
Entity type:Individual
Prefix:
First Name:CORLETTE
Middle Name:GANTT
Last Name:KELLY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MRS
Other - First Name:CORLETTE
Other - Middle Name:GANTT
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:1275 SHILOH RD NW STE 3030
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-7186
Mailing Address - Country:US
Mailing Address - Phone:470-296-1775
Mailing Address - Fax:
Practice Address - Street 1:1275 SHILOH RD NW STE 3030
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-7186
Practice Address - Country:US
Practice Address - Phone:470-296-1775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009229101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional