Provider Demographics
NPI:1770013377
Name:OMEALLY, KIRA PATRICIA
Entity Type:Individual
Prefix:
First Name:KIRA
Middle Name:PATRICIA
Last Name:OMEALLY
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 1:2106 LINDA SUE CIR APT 105
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-6162
Mailing Address - Country:US
Mailing Address - Phone:772-634-5403
Mailing Address - Fax:
Practice Address - Street 1:2106 LINDA SUE CIRCLE #105
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982
Practice Address - Country:US
Practice Address - Phone:772-634-5403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106E00000X
106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018834400Medicaid