Provider Demographics
NPI:1043260417
Name:KILEY, SUSAN NELSON (LMHC)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:NELSON
Last Name:KILEY
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 FALLS TRL
Mailing Address - Street 2:
Mailing Address - City:MALABAR
Mailing Address - State:FL
Mailing Address - Zip Code:32950-6810
Mailing Address - Country:US
Mailing Address - Phone:321-724-4969
Mailing Address - Fax:321-242-7464
Practice Address - Street 1:1425 AURORA RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-5384
Practice Address - Country:US
Practice Address - Phone:321-242-3110
Practice Address - Fax:321-242-7464
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH2665101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health