Provider Demographics
NPI:1780409326
Name:KELLY, SAMANTHA (BS)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 PEARY CT UNIT B
Mailing Address - Street 2:
Mailing Address - City:KEY WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33040-7855
Mailing Address - Country:US
Mailing Address - Phone:520-350-0286
Mailing Address - Fax:
Practice Address - Street 1:1205 4TH ST
Practice Address - Street 2:
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040-3707
Practice Address - Country:US
Practice Address - Phone:305-434-7660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)