Provider Demographics
NPI:1245855394
Name:RYALS, KELLEY
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:RYALS
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 1:6704 PLANTATION RD UNIT C
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-4207
Mailing Address - Country:US
Mailing Address - Phone:850-291-4249
Mailing Address - Fax:
Practice Address - Street 1:6704 PLANTATION RD UNIT C
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-4207
Practice Address - Country:US
Practice Address - Phone:850-291-4249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-15
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH17803101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH17803OtherDEPT OF HEALTH LICENSURE