Healthcare Provider Details

I. General information

NPI: 1750772380
Provider Name (Legal Business Name): WHITLEE LAINA KELLEY BS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2015
Last Update Date: 04/24/2019
Certification Date:
Deactivation Date: 03/10/2018
Reactivation Date: 04/24/2019

III. Provider practice location address

112 TITAN DRIVE
FLORENCE AL
35630
US

IV. Provider business mailing address

112 TITAN DRIVE
FLORENCE AL
35630
US

V. Phone/Fax

Practice location:
  • Phone: 256-275-7089
  • Fax: 256-341-0747
Mailing address:
  • Phone: 256-275-7089
  • Fax: 256-341-0747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: