Provider Demographics
NPI:1750010229
Name:PROPHETER, KELSEY RENEE
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:RENEE
Last Name:PROPHETER
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 1:13310 SOLOMAN CT
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34669-2141
Mailing Address - Country:US
Mailing Address - Phone:815-441-7103
Mailing Address - Fax:
Practice Address - Street 1:1280 FINLAND DR
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609-5550
Practice Address - Country:US
Practice Address - Phone:813-926-5454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician