Provider Demographics
NPI:1598302192
Name:ZELLNER, KEONDRIA J
Entity Type:Individual
Prefix:
First Name:KEONDRIA
Middle Name:J
Last Name:ZELLNER
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 1:130 CORRIDOR RD UNIT 3292
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32004-7833
Mailing Address - Country:US
Mailing Address - Phone:904-638-6388
Mailing Address - Fax:904-485-8829
Practice Address - Street 1:10 LONG CREEK LN
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-8601
Practice Address - Country:US
Practice Address - Phone:904-638-6388
Practice Address - Fax:904-485-8829
Is Sole Proprietor?:No
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-17-41307106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician