Provider Demographics
NPI:1457852972
Name:DAMBRA, KELLY A (LMHC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:DAMBRA
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 S LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LANTANA
Mailing Address - State:FL
Mailing Address - Zip Code:33462-4628
Mailing Address - Country:US
Mailing Address - Phone:561-866-9776
Mailing Address - Fax:
Practice Address - Street 1:224 DATURA ST STE 214
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-5630
Practice Address - Country:US
Practice Address - Phone:561-571-8164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH14626OtherDEPARTMENT OF HEALTH