MEDICARE: KELSEY RENEE PROPHETER

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1750010229
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSEY RENEE PROPHETER

Provider Business Mailing Address
First Line	:	13310 SOLOMAN CT
Second Line	:
City	:	HUDSON
State	:	FL
Zip	:	34669-2141
Country	:	US
Telephone Number	:	815-441-7103
Fax Number	:

Provider Business Practice Location Address
First Line	:	1280 FINLAND DR
Second Line	:
City	:	SPRING HILL
State	:	FL
Zip	:	34609-5550
Country	:	US
Telephone Number	:	813-926-5454
Fax Number	:

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

Provider Enumeration Date	:	06/08/2022
Last Update Date	:	06/08/2022

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Directions to “ KELSEY RENEE PROPHETER ” Practice Location

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