Provider Demographics
NPI:1013514611
Name:VANSCIVER, KELLY JEAN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:VANSCIVER
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 1:242 HURST RD NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-1566
Mailing Address - Country:US
Mailing Address - Phone:321-614-8705
Mailing Address - Fax:
Practice Address - Street 1:1200 N CENTRAL AVE STE 110
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4439
Practice Address - Country:US
Practice Address - Phone:407-201-7429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-06
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist