Provider Demographics
NPI:1235543216
Name:KELLEY, ERIN (MED)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 LA COSTA ST
Mailing Address - Street 2:#404
Mailing Address - City:MELBOURNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32951-3420
Mailing Address - Country:US
Mailing Address - Phone:904-322-0084
Mailing Address - Fax:
Practice Address - Street 1:107 LA COSTA ST
Practice Address - Street 2:#404
Practice Address - City:MELBOURNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32951-3420
Practice Address - Country:US
Practice Address - Phone:904-322-0084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH11330101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health