Provider Demographics
NPI:1720718091
Name:POULOS, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:POULOS
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 1:1005 NEWCASTLE A
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33434-4619
Mailing Address - Country:US
Mailing Address - Phone:646-515-9301
Mailing Address - Fax:
Practice Address - Street 1:3520 OAKS WAY APT 904
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33069-5387
Practice Address - Country:US
Practice Address - Phone:737-242-8222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst