Provider Demographics
NPI:1881874618
Name:HYDE, KELLIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:KELLIE
Middle Name:
Last Name:HYDE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5140 NORTHWIND BLVD
Mailing Address - Street 2:CONDO 305 EAST
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-4506
Mailing Address - Country:US
Mailing Address - Phone:352-262-8751
Mailing Address - Fax:
Practice Address - Street 1:5140 NORTHWIND BLVD
Practice Address - Street 2:CONDO 305 EAST
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-4506
Practice Address - Country:US
Practice Address - Phone:352-262-8751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8196103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist