Provider Demographics
NPI:1154942688
Name:NIELLY, KENTAYA (MS, LMHC)
Entity type:Individual
Prefix:
First Name:KENTAYA
Middle Name:
Last Name:NIELLY
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4112 SW 27TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33023-4466
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4112 SW 27TH ST
Practice Address - Street 2:
Practice Address - City:WEST PARK
Practice Address - State:FL
Practice Address - Zip Code:33023-4466
Practice Address - Country:US
Practice Address - Phone:954-445-5622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-06
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor