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General NPI Number Information
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NPI Number | 1932104288
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Entity Type | Individual
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Provider Name | KELLY T CLOUSE MD
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Gender | Male
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Dates
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Enumeration Date | 06/14/2005
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Last Update Date | 01/21/2022
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Provider Practice Location Address
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Address Line | 2021 PROFESSIONAL CENTER DR STE 101
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City | ORANGE PARK
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State | FL
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Zip | 32073-4461
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Country | US
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Telephone | 904-213-9210
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Fax | 904-213-9211
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Provider Business Mailing Address
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Address Line | 2021 PROFESSIONAL CENTER DR STE 101
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City | ORANGE PARK
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State | FL
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Zip | 32073-4461
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Country | US
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Telephone | 904-213-9210
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Fax | 904-213-9211
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | ME110938
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 46974
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License Number State | WI
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