Provider Demographics
NPI:1760635460
Name:TARR, KELLY BRENNAN
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:BRENNAN
Last Name:TARR
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 1:7410 S US HIGHWAY 1
Mailing Address - Street 2:SUITE 401
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-1432
Mailing Address - Country:US
Mailing Address - Phone:772-340-5044
Mailing Address - Fax:
Practice Address - Street 1:7410 S US HIGHWAY 1
Practice Address - Street 2:SUITE 401
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-1432
Practice Address - Country:US
Practice Address - Phone:772-340-5044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH5420101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health