Healthcare Provider Details

I. General information

NPI: 1790393973
Provider Name (Legal Business Name): KELLEY HOLLADAY PHD, LMHC, LPCC, MAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 S OCEAN SHORE BLVD STE 218
FLAGLER BEACH FL
32136-3602
US

IV. Provider business mailing address

712 S OCEAN SHORE BLVD STE 218
FLAGLER BEACH FL
32136-3602
US

V. Phone/Fax

Practice location:
  • Phone: 904-894-1754
  • Fax:
Mailing address:
  • Phone: 904-894-1754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12648
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: