Healthcare Provider Details

I. General information

NPI: 1114717618
Provider Name (Legal Business Name): KELSIE-ANN BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2025
Last Update Date: 02/26/2026
Certification Date: 02/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3223 NW 10TH TER STE 610
FORT LAUDERDALE FL
33309-5940
US

IV. Provider business mailing address

5104 LAUREL CIR
TAMARAC FL
33319-3145
US

V. Phone/Fax

Practice location:
  • Phone: 954-802-1428
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: