Provider Demographics
NPI:1114429024
Name:KIZIS, KELLIE ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:ANN
Last Name:KIZIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 AVENUE O SE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-4533
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4902 EISENHOWER BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-6310
Practice Address - Country:US
Practice Address - Phone:813-290-8560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW146961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical