Provider Demographics
NPI:1679210587
Name:SUMPLE, KALIE (BS)
Entity Type:Individual
Prefix:
First Name:KALIE
Middle Name:
Last Name:SUMPLE
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 E PACKWOOD AVE APT A210
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-6207
Mailing Address - Country:US
Mailing Address - Phone:203-525-8798
Mailing Address - Fax:
Practice Address - Street 1:11315 CORPORATE BLVD STE 105
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-8340
Practice Address - Country:US
Practice Address - Phone:407-534-0186
Practice Address - Fax:321-972-3982
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-13
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH11960101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty