Healthcare Provider Details

I. General information

NPI: 1669688644
Provider Name (Legal Business Name): DAVID G KELLEY D.MIN.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 COURTNEY DR SUITE # 2
FORT MYERS FL
33901-9034
US

IV. Provider business mailing address

1950 COURTNEY DRIVE SUITE # 2
FORT MYERS FL
33901
US

V. Phone/Fax

Practice location:
  • Phone: 239-278-3231
  • Fax: 239-278-4227
Mailing address:
  • Phone: 239-278-3231
  • Fax: 239-278-4227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMT0000494
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: