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General NPI Number Information
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NPI Number | 1184434607
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Entity Type | Individual
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Provider Name | KELLY MARIE KISIDA
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Gender | Female
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Dates
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Enumeration Date | 01/08/2025
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Last Update Date | 01/08/2025
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Provider Practice Location Address
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Address Line | 853 SR 436 SUITE 2099
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City | CASSELBERRY
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State | FL
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Zip | 32707
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Country | US
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Telephone | 407-906-6167
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Fax |
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Provider Business Mailing Address
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Address Line | 9775 DORIATH CIR
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City | ORLANDO
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State | FL
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Zip | 32825-8796
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Country | US
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Telephone | 941-374-3332
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 27040
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License Number State | FL
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