=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366927477
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY ELIZABETH SCHULLER LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2018
-----------------------------------------------------
Last Update Date | 08/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8348 NANDINA DR
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34240-9523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-321-2038
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 227 LINCOLN AVE
-----------------------------------------------------
City | TOTOWA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07512-2123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 37AC00305200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 37PC00642200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------