Provider Demographics
NPI:1689906604
Name:ILSLEY, KELLY ROSE (PSYD, ABPP, BCBA-D)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ROSE
Last Name:ILSLEY
Suffix:
Gender:F
Credentials:PSYD, ABPP, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11120 S CROWN WAY STE 1
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-8718
Mailing Address - Country:US
Mailing Address - Phone:561-790-1191
Mailing Address - Fax:
Practice Address - Street 1:11120 S CROWN WAY STE 1
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-8718
Practice Address - Country:US
Practice Address - Phone:561-790-1191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-01
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7971103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical