Provider Demographics
NPI:1134752926
Name:GYENING, KELLAE KATHLEEN GIOVANNI
Entity type:Individual
Prefix:
First Name:KELLAE
Middle Name:KATHLEEN GIOVANNI
Last Name:GYENING
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 1:2468 DAVENTRY WALK
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-5844
Mailing Address - Country:US
Mailing Address - Phone:770-406-6059
Mailing Address - Fax:
Practice Address - Street 1:500 FAIRWAY DR STE 102
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33441-1817
Practice Address - Country:US
Practice Address - Phone:954-603-7885
Practice Address - Fax:954-342-0273
Is Sole Proprietor?:No
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician