Provider Demographics
NPI:1720326408
Name:CARLSON, KELLY L (LMHC, MED)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LMHC, MED
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:CARLSON, LLC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5500 MILITARY TRL
Mailing Address - Street 2:#22-106
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-2869
Mailing Address - Country:US
Mailing Address - Phone:561-354-8795
Mailing Address - Fax:561-743-7165
Practice Address - Street 1:5500 MILITARY TRL
Practice Address - Street 2:#22-106
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-2869
Practice Address - Country:US
Practice Address - Phone:561-354-8795
Practice Address - Fax:561-743-7165
Is Sole Proprietor?:No
Enumeration Date:2013-01-30
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH8729101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health