Provider Demographics
NPI:1952823494
Name:GONZALES, KELSEY
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:GONZALES
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:PO BOX 832
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33780-0832
Mailing Address - Country:US
Mailing Address - Phone:732-492-5369
Mailing Address - Fax:
Practice Address - Street 1:7 CARRIE DR
Practice Address - Street 2:
Practice Address - City:MATAWAN
Practice Address - State:NJ
Practice Address - Zip Code:07747-6422
Practice Address - Country:US
Practice Address - Phone:732-824-7185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-15
Last Update Date:2017-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty