Provider Demographics
NPI:1720283674
Name:RICHARDS, KELLY ELIZABETH (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ELIZABETH
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:ELIZABETH
Other - Last Name:SWAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:2 ROSSETTER CIR
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-4123
Mailing Address - Country:US
Mailing Address - Phone:321-951-3949
Mailing Address - Fax:
Practice Address - Street 1:21 W FEE AVE
Practice Address - Street 2:SUITE G
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-4402
Practice Address - Country:US
Practice Address - Phone:321-951-3949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW80791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical