MEDICARE: KIM A KELLY LMHC

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	101YM0800X	Mental Health Counselor	MH8940	FL

General Provider Information

NPI Number	:	1851630412
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM A KELLY LMHC

Provider Business Mailing Address
First Line	:	4638 ROYAL AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32205-4952
Country	:	US
Telephone Number	:	904-647-7567
Fax Number	:	904-647-7568

Provider Business Practice Location Address
First Line	:	2528 OAK ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32204-4504
Country	:	US
Telephone Number	:	904-647-7567
Fax Number	:

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

Provider Enumeration Date	:	02/01/2013
Last Update Date	:	07/06/2013

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