Provider Demographics
NPI:1851355689
Name:KELLY, BARBARA E (PHD)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:E
Last Name:KELLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E VENTRIS AVE
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-5626
Mailing Address - Country:US
Mailing Address - Phone:407-951-8812
Mailing Address - Fax:407-951-8869
Practice Address - Street 1:100 E VENTRIS AVE
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5626
Practice Address - Country:US
Practice Address - Phone:407-951-8812
Practice Address - Fax:407-951-8869
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5762103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54367YMedicare ID - Type Unspecified