Provider Demographics
NPI:1437291747
Name:KELLY, CARLA DEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CARLA
Middle Name:DEE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:CARLA
Other - Middle Name:KELLY
Other - Last Name:DEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:209 S COOLIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609
Mailing Address - Country:US
Mailing Address - Phone:813-286-0320
Mailing Address - Fax:813-207-0022
Practice Address - Street 1:4100 W KENNEDY BLVD
Practice Address - Street 2:#214
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609
Practice Address - Country:US
Practice Address - Phone:813-289-6502
Practice Address - Fax:813-207-0022
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0002141103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
00073171OtherBLUE CROSS BLUE SHIELD
00073171OtherBLUE CROSS BLUE SHIELD