Provider Demographics
NPI:1356906523
Name:KELLY, MORGAN
Entity type:Individual
Prefix:
First Name:MORGAN
Middle Name:
Last Name:KELLY
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 1:1426 SE NORTH BALCOURT CT
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7810
Mailing Address - Country:US
Mailing Address - Phone:407-777-7413
Mailing Address - Fax:
Practice Address - Street 1:1765 SW CAPTAINS PL
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-1747
Practice Address - Country:US
Practice Address - Phone:772-266-8727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-03
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19-94436106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician