Provider Demographics
NPI:1326287145
Name:URBAN, KELLY (PHD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:URBAN
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 1:6701 SEAGATE DR
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-7452
Mailing Address - Country:US
Mailing Address - Phone:228-229-4125
Mailing Address - Fax:
Practice Address - Street 1:6701 SEAGATE DR
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-7452
Practice Address - Country:US
Practice Address - Phone:228-229-4125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-18
Last Update Date:2015-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX338411041C0700X
FLSW119751041C0700X
MSC81571041C0700X
TN58551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1487159-01Medicaid