Provider Demographics
NPI:1598264012
Name:STERRETT, KELLIANN
Entity Type:Individual
Prefix:MRS
First Name:KELLIANN
Middle Name:
Last Name:STERRETT
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 1:2471 SE PINERO RD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5326
Mailing Address - Country:US
Mailing Address - Phone:772-475-5557
Mailing Address - Fax:
Practice Address - Street 1:19022 NE 29TH AVE
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-2823
Practice Address - Country:US
Practice Address - Phone:305-931-1617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-10
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TB0200X
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral