Provider Demographics
NPI:1790491561
Name:WESSEL, KELLIE NICOLE
Entity Type:Individual
Prefix:MISS
First Name:KELLIE
Middle Name:NICOLE
Last Name:WESSEL
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 1:1600 E ROBINSON ST STE 250
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-5955
Mailing Address - Country:US
Mailing Address - Phone:407-423-3327
Mailing Address - Fax:
Practice Address - Street 1:1600 E ROBINSON ST STE 250
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5955
Practice Address - Country:US
Practice Address - Phone:407-423-3327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH23600101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health