Provider Demographics
NPI:1518253897
Name:VALK, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:VALK
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 1:5147 S LAKELAND DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2610
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5147 S LAKELAND DR
Practice Address - Street 2:SUITE 4
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2610
Practice Address - Country:US
Practice Address - Phone:863-825-5277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-24
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 8369101YM0800X, 101Y00000X
FLMH14567101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL679096896-67Medicaid
FL59-2867920OtherEIN