Provider Demographics
NPI:1598337792
Name:ELIE, KETHIA
Entity Type:Individual
Prefix:
First Name:KETHIA
Middle Name:
Last Name:ELIE
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 1:1924 DAIRY RD
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-4046
Mailing Address - Country:US
Mailing Address - Phone:321-256-8000
Mailing Address - Fax:561-616-8412
Practice Address - Street 1:1924 DAIRY RD
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-4046
Practice Address - Country:US
Practice Address - Phone:321-256-8000
Practice Address - Fax:561-616-8412
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-15
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist