MEDICARE: KELLY HAMMERBERG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MH7698	FL

General Provider Information

NPI Number	:	1104596808
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY HAMMERBERG

Provider Business Mailing Address
First Line	:	3520 CLEVELAND HEIGHTS BLVD APT 35
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33803-4917
Country	:	US
Telephone Number	:	407-929-5284
Fax Number	:

Provider Business Practice Location Address
First Line	:	3520 CLEVELAND HEIGHTS BLVD APT 35
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33803-4917
Country	:	US
Telephone Number	:	407-929-5284
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2021
Last Update Date	:	09/15/2021

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