Healthcare Provider Details

I. General information

NPI: 1750112736
Provider Name (Legal Business Name): ANTHONY DAVID KELLEY D.MIN., LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2024
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11310 CALLAWAY POND DR
RIVERVIEW FL
33579-2347
US

IV. Provider business mailing address

CMR 469 BOX 931
APO AE
09227-1010
US

V. Phone/Fax

Practice location:
  • Phone: 656-208-8705
  • Fax:
Mailing address:
  • Phone: 859-577-0881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number205458
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: