Kelly Broadwater Pickell, MA, LPA, LPC, CEDS

Primary specialty

PsychologistTaxonomy code 103T00000X

License

2481 Issued in NC

Practice address

3240 Burnt Mill Dr
Suite 1
Wilmington, NC 28403-2576

Phone

(910) 790-9500

Fax

(910) 796-8111

NPI assigned

Sep 28, 2006

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Kelly Broadwater Professional name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Master of Arts

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1159401600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1438041600000",
    "number": "1881786945",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3240 BURNT MILL DR",
            "address_2": "SUITE 1",
            "city": "WILMINGTON",
            "state": "NC",
            "postal_code": "284032576",
            "telephone_number": "910-790-9500",
            "fax_number": "910-796-8111"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3240 BURNT MILL DR",
            "address_2": "SUITE 1",
            "city": "WILMINGTON",
            "state": "NC",
            "postal_code": "284032576",
            "telephone_number": "910-790-9500",
            "fax_number": "910-796-8111"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PICKELL",
        "first_name": "KELLY",
        "middle_name": "BROADWATER",
        "credential": "MA, LPA, LPC, CEDS",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-09-28",
        "last_updated": "2015-07-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "NC",
            "license": "2481",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "046XA",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "KELLY",
            "last_name": "BROADWATER",
            "credential": "MA, LPA, LPC, CEDS",
            "code": "2",
            "type": "Professional Name"
        }
    ]
}

• Physician Alliance for Mental Health LLC
• Physician Alliance for Mental Health, LLC
• Physician Alliance of Mental Health
• Physicians Choice Medical Equipment
• Panida Piboolnurak, MD
• Tynisha Jeanette Pickett
• Picklesimer & Plasky, DDS
• John D. Picklesimer, D.D.S.
• Zoya Picklesimer, LCAS, LPC
• Caitlin Pieklo

• Psychologist in Wilmington, NC
• Providers in Wilmington, NC by specialty
• Psychologist in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 28, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.