Healthcare Provider Details

I. General information

NPI: 1609277656
Provider Name (Legal Business Name): KELLY CARLSON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2014
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2026 SE OCEAN BLVD
STUART FL
34996-3304
US

IV. Provider business mailing address

5500 MILITARY TRAIL #22-106
JUPITER FL
33458
US

V. Phone/Fax

Practice location:
  • Phone: 561-354-8795
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH8729
License Number StateFL

VIII. Authorized Official

Name: KELLY CARLSON
Title or Position: OWNER
Credential: LMHC
Phone: 561-354-8795