Provider Demographics
NPI:1356830343
Name:MYERS, KELLY J (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:MYERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 ATLANTIC ST APT 3B
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32951-2342
Mailing Address - Country:US
Mailing Address - Phone:321-339-6757
Mailing Address - Fax:
Practice Address - Street 1:1706 ATLANTIC ST APT 3B
Practice Address - Street 2:
Practice Address - City:MELBOURNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32951-2342
Practice Address - Country:US
Practice Address - Phone:321-339-6757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-04
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW150601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical