Provider Demographics
NPI:1275918740
Name:NEGRON, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:NEGRON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3313 DELANA WAY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-5742
Mailing Address - Country:US
Mailing Address - Phone:650-213-2283
Mailing Address - Fax:
Practice Address - Street 1:11575 CITY HALL PROMENADE UNIT 151
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-7585
Practice Address - Country:US
Practice Address - Phone:650-213-2283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-27
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL222Q00000X
TX15098103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist