Provider Demographics
NPI:1669797171
Name:KELLY, SAMUEL E
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:E
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 W OAKLAND PARK BLVD
Mailing Address - Street 2:STE A1
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33311-1243
Mailing Address - Country:US
Mailing Address - Phone:954-202-9334
Mailing Address - Fax:954-202-7912
Practice Address - Street 1:2901 W OAKLAND PARK BLVD
Practice Address - Street 2:STE A1
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33311-1243
Practice Address - Country:US
Practice Address - Phone:954-202-9334
Practice Address - Fax:954-202-7912
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-29
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH3876101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL676033396Medicaid
FL676033398Medicaid