Provider Demographics
NPI:1114742079
Name:ROBERTS, KELLY DAVIS (LMT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:DAVIS
Last Name:ROBERTS
Suffix:
Gender:
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 SE WALDRON TER
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-5529
Mailing Address - Country:US
Mailing Address - Phone:386-400-3140
Mailing Address - Fax:386-406-8013
Practice Address - Street 1:738 SW MAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5768
Practice Address - Country:US
Practice Address - Phone:386-400-3140
Practice Address - Fax:386-406-8013
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-16
Last Update Date:2025-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA64119225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1558067579OtherGROUP NPI