Provider Demographics
NPI:1619570496
Name:JUSTICE, KELSEY
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:JUSTICE
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 1:4629 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583-4107
Mailing Address - Country:US
Mailing Address - Phone:850-503-6636
Mailing Address - Fax:850-626-6132
Practice Address - Street 1:4629 CHURCH ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32583-4107
Practice Address - Country:US
Practice Address - Phone:850-503-6636
Practice Address - Fax:850-626-6132
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-20-145057106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician