Provider Demographics
NPI:1114542354
Name:WALKER, KELLY D (CIPS, CMHC)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:D
Last Name:WALKER
Suffix:
Gender:F
Credentials:CIPS, CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:792 HIGHWAY 20
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32466-3517
Mailing Address - Country:US
Mailing Address - Phone:850-743-9978
Mailing Address - Fax:
Practice Address - Street 1:792 HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32466-3517
Practice Address - Country:US
Practice Address - Phone:850-743-9978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-13
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL319062101YA0400X
FL517068101YM0800X
FL0090HTG146D00000X
FL590116172V00000X
FL379114405300000X
FL36-89142101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response AttendantGroup - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
No405300000XOther Service ProvidersPrevention ProfessionalGroup - Multi-Specialty