Healthcare Provider Details

I. General information

NPI: 1982442497
Provider Name (Legal Business Name): KELLY R GENTRY RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2024
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2134 KENTUCKY AVE
WINTER PARK FL
32789-4535
US

IV. Provider business mailing address

1509 E COLONIAL DR STE 300
ORLANDO FL
32803-4729
US

V. Phone/Fax

Practice location:
  • Phone: 407-317-5429
  • Fax: 321-800-7201
Mailing address:
  • Phone: 407-317-5429
  • Fax: 321-800-7201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-350776
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: