Provider Demographics
NPI:1073044780
Name:SAKALA, KELLY (MED, CRC, PVE)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SAKALA
Suffix:
Gender:F
Credentials:MED, CRC, PVE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 SW GOODRICH ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-2039
Mailing Address - Country:US
Mailing Address - Phone:561-305-2607
Mailing Address - Fax:
Practice Address - Street 1:2632 SW PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-2845
Practice Address - Country:US
Practice Address - Phone:561-305-2607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
FL00116485101YA0400X, 390200000X, 405300000X
FL00224173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No173000000XOther Service ProvidersLegal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program