Healthcare Provider Details

I. General information

NPI: 1366749574
Provider Name (Legal Business Name): KELLIAN L KLIPSTINE L.M.H.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2011
Last Update Date: 02/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

344 PASEO REYES DRIVE
SAINT AUGUSTINE FL
32095-8464
US

IV. Provider business mailing address

344 PASEO REYES DRIVE
SAINT AUGUSTINE FL
32095-8464
US

V. Phone/Fax

Practice location:
  • Phone: 904-315-6107
  • Fax:
Mailing address:
  • Phone: 904-315-6107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH 9821
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: