Provider Demographics
NPI:1518258722
Name:GIEGERICH, KELLY ANN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:GIEGERICH
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 1:3111 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33405-1557
Mailing Address - Country:US
Mailing Address - Phone:561-612-6000
Mailing Address - Fax:561-612-6095
Practice Address - Street 1:4101 PARKER AVE
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33405-2507
Practice Address - Country:US
Practice Address - Phone:561-616-1222
Practice Address - Fax:561-616-1230
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-21
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA088351101YM0800X
171M00000X
FLMH10731101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002142800Medicaid