Provider Demographics
NPI:1154833739
Name:KELLEY, DESIREE (MSW,RCSWI)
Entity Type:Individual
Prefix:MRS
First Name:DESIREE
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MSW,RCSWI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20093 SW 81ST ST
Mailing Address - Street 2:
Mailing Address - City:DUNNELLON
Mailing Address - State:FL
Mailing Address - Zip Code:34431-5211
Mailing Address - Country:US
Mailing Address - Phone:352-601-1784
Mailing Address - Fax:
Practice Address - Street 1:708 NE 6TH ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34428-3704
Practice Address - Country:US
Practice Address - Phone:352-228-4969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-03
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty