Provider Demographics
NPI:1295562288
Name:FITZGERALD, KELCEE REBECCA
Entity type:Individual
Prefix:
First Name:KELCEE
Middle Name:REBECCA
Last Name:FITZGERALD
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 1:1000 PATRIOT LN APT 326
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-7405
Mailing Address - Country:US
Mailing Address - Phone:601-851-6808
Mailing Address - Fax:
Practice Address - Street 1:1001 INDUSTRIAL DR # ANA
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-6943
Practice Address - Country:US
Practice Address - Phone:850-400-6098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-377483106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician