Provider Demographics
NPI:1780989434
Name:KELLEY, CYNTHIA ROBYN (MSW LICSW)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:ROBYN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 CECILIA CT
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-7305
Mailing Address - Country:US
Mailing Address - Phone:253-625-6060
Mailing Address - Fax:
Practice Address - Street 1:199 CECILIA CT
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-7305
Practice Address - Country:US
Practice Address - Phone:253-625-6060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-11
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW 000062441041C0700X
FLSW175571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2115955Medicaid