Provider Demographics
NPI:1457628646
Name:TIM KELLY, LCSW, PSYCHOTHERAPIST, PA
Entity Type:Organization
Organization Name:TIM KELLY, LCSW, PSYCHOTHERAPIST, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:MATTHIAS
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:305-872-3187
Mailing Address - Street 1:3706 N ROOSEVELT BLVD
Mailing Address - Street 2:B
Mailing Address - City:KEY WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33040-4566
Mailing Address - Country:US
Mailing Address - Phone:305-294-1277
Mailing Address - Fax:305-294-8927
Practice Address - Street 1:3706 N ROOSEVELT BLVD
Practice Address - Street 2:B
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040-4566
Practice Address - Country:US
Practice Address - Phone:305-294-1277
Practice Address - Fax:305-294-8927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW3573251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ7923Medicare PIN