Provider Demographics
NPI:1083087456
Name:GILL, KELLEY (PHD)
Entity Type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:
Last Name:GILL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1752 NW 3RD TER
Mailing Address - Street 2:#213
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33311-4885
Mailing Address - Country:US
Mailing Address - Phone:203-430-9108
Mailing Address - Fax:
Practice Address - Street 1:1752 NW 3RD TER
Practice Address - Street 2:#213
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33311-4885
Practice Address - Country:US
Practice Address - Phone:203-430-9108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 9562103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical