Provider Demographics
NPI:1194299578
Name:KILGORE, KELLERY (PSYD)
Entity type:Individual
Prefix:DR
First Name:KELLERY
Middle Name:
Last Name:KILGORE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:KELLERY
Other - Middle Name:
Other - Last Name:GILBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2634 CAPITAL CIR NE BLDG B
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4106
Mailing Address - Country:US
Mailing Address - Phone:850-523-3333
Mailing Address - Fax:
Practice Address - Street 1:2634 CAPITAL CIR NE BLDG B
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4106
Practice Address - Country:US
Practice Address - Phone:850-523-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY10229103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical