Healthcare Provider Details

I. General information

NPI: 1043260417
Provider Name (Legal Business Name): SUSAN NELSON KILEY L.M.H.C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 AURORA RD
MELBOURNE FL
32935-5384
US

IV. Provider business mailing address

930 FALLS TRL
MALABAR FL
32950-6810
US

V. Phone/Fax

Practice location:
  • Phone: 321-242-3110
  • Fax: 321-242-7464
Mailing address:
  • Phone: 321-724-4969
  • Fax: 321-242-7464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH2665
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: