Healthcare Provider Details

I. General information

NPI: 1780409326
Provider Name (Legal Business Name): SAMANTHA KELLY BS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 4TH ST
KEY WEST FL
33040-3707
US

IV. Provider business mailing address

628 PEARY CT UNIT B
KEY WEST FL
33040-7855
US

V. Phone/Fax

Practice location:
  • Phone: 305-434-7660
  • Fax:
Mailing address:
  • Phone: 520-350-0286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: