Provider Demographics
NPI:1760896708
Name:KELLY, STACEY
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:KELLY
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 1:7751 HOOD ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-2525
Mailing Address - Country:US
Mailing Address - Phone:754-204-5141
Mailing Address - Fax:
Practice Address - Street 1:7751 HOOD ST
Practice Address - Street 2:7751 HOOD ST
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-2525
Practice Address - Country:US
Practice Address - Phone:754-204-5141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-18
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101Y00000XBehavioral Health & Social Service ProvidersCounselor