Provider Demographics
NPI:1457313330
Name:KELLY, SHANNON (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6001 BRICK CT
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-9425
Mailing Address - Country:US
Mailing Address - Phone:407-671-1123
Mailing Address - Fax:407-671-1233
Practice Address - Street 1:6001 BRICK CT
Practice Address - Street 2:SUITE 201
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-9425
Practice Address - Country:US
Practice Address - Phone:407-671-1123
Practice Address - Fax:407-671-1233
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7017103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74434ZMedicare ID - Type Unspecified