MEDICARE: DR. KELLEY GILL PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PY 9562	FL

General Provider Information

NPI Number	:	1083087456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLEY GILL PH.D.

Provider Business Mailing Address
First Line	:	1752 NW 3RD TER
Second Line	:	#213
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33311-4885
Country	:	US
Telephone Number	:	203-430-9108
Fax Number	:

Provider Business Practice Location Address
First Line	:	1752 NW 3RD TER
Second Line	:	#213
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33311-4885
Country	:	US
Telephone Number	:	203-430-9108
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2015
Last Update Date	:	11/07/2019

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