Healthcare Provider Details

I. General information

NPI: 1023955226
Provider Name (Legal Business Name): KELLY REAL
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 SW 84TH AVE
PLANTATION FL
33324-2708
US

IV. Provider business mailing address

205 SW 84TH AVE
PLANTATION FL
33324-2708
US

V. Phone/Fax

Practice location:
  • Phone: 954-382-5570
  • Fax: 954-250-2529
Mailing address:
  • Phone: 954-382-5570
  • Fax: 954-250-2529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: