Healthcare Provider Details

I. General information

NPI: 1114542354
Provider Name (Legal Business Name): KELLY D WALKER CIPS, CMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2020
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

792 HIGHWAY 20
YOUNGSTOWN FL
32466-3517
US

IV. Provider business mailing address

792 HIGHWAY 20
YOUNGSTOWN FL
32466-3517
US

V. Phone/Fax

Practice location:
  • Phone: 850-743-9978
  • Fax:
Mailing address:
  • Phone: 850-743-9978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number319062
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number517068
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code146D00000X
TaxonomyPersonal Emergency Response Attendant
License Number0090HTG
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number590116
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number379114
License Number StateFL
# 6
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number36-89142
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: