Provider Demographics
NPI:1508588047
Name:KJELDSEN, LARA
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:KJELDSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 E INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-4414
Mailing Address - Country:US
Mailing Address - Phone:386-956-2531
Mailing Address - Fax:
Practice Address - Street 1:1217 HUFFSTETLER DR STE 11
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-8225
Practice Address - Country:US
Practice Address - Phone:352-315-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH22208101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health