Provider Demographics
NPI:1679092068
Name:VISALLI-BETTAG, KELSEA MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KELSEA
Middle Name:MARIE
Last Name:VISALLI-BETTAG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 NW 16TH AVE UNIT 172
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601-4012
Mailing Address - Country:US
Mailing Address - Phone:260-249-7505
Mailing Address - Fax:
Practice Address - Street 1:806 NW 16TH AVE UNIT 172
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-4012
Practice Address - Country:US
Practice Address - Phone:260-249-7505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-17
Last Update Date:2023-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CT3953103TC1900X
FL11490103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty