Provider Demographics
NPI:1952857377
Name:RICH, KELSIE (MS)
Entity Type:Individual
Prefix:
First Name:KELSIE
Middle Name:
Last Name:RICH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 E 139TH AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-3420
Mailing Address - Country:US
Mailing Address - Phone:813-972-3201
Mailing Address - Fax:813-632-0933
Practice Address - Street 1:1109 E 139TH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-3420
Practice Address - Country:US
Practice Address - Phone:813-972-3201
Practice Address - Fax:813-632-0933
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness