Provider Demographics
NPI:1053334151
Name:KELLY, KATHLEEN J (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:J
Last Name:KELLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6651 SE 8TH ST RD
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34472
Mailing Address - Country:US
Mailing Address - Phone:352-454-4701
Mailing Address - Fax:
Practice Address - Street 1:1701 NE 42ND AVE
Practice Address - Street 2:STE 102
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34470
Practice Address - Country:US
Practice Address - Phone:352-351-4940
Practice Address - Fax:352-351-8902
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7221103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75334OtherBLUE CROSS BLUE SHIELD