Healthcare Provider Details

I. General information

NPI: 1326287145
Provider Name (Legal Business Name): KELLY URBAN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2009
Last Update Date: 05/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 SEAGATE DR
NAVARRE FL
32566-7452
US

IV. Provider business mailing address

6701 SEAGATE DR
NAVARRE FL
32566-7452
US

V. Phone/Fax

Practice location:
  • Phone: 228-229-4125
  • Fax:
Mailing address:
  • Phone: 228-229-4125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number33841
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW11975
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC8157
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5855
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: