Provider Demographics
NPI:1346967023
Name:KELLY, CRYSTAL ANN (MS, LMFT)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:ANN
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3466 SW PLUTO ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-3483
Mailing Address - Country:US
Mailing Address - Phone:954-465-0993
Mailing Address - Fax:
Practice Address - Street 1:2222 COLONIAL RD STE 100
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-5309
Practice Address - Country:US
Practice Address - Phone:772-489-4726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-24
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT4455106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist