Provider Demographics
NPI:1063890721
Name:BRINKER, KELLI ELIZABETH (BCABA)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:ELIZABETH
Last Name:BRINKER
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 BLACK DIAMOND DR
Mailing Address - Street 2:APT 1211
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-0264
Mailing Address - Country:US
Mailing Address - Phone:937-475-0265
Mailing Address - Fax:
Practice Address - Street 1:4750 COLLEGIATE DR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-1000
Practice Address - Country:US
Practice Address - Phone:937-475-0265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-14-6387103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst