Provider Demographics
NPI:1538608112
Name:KALENA SMITH-FULWILEY, LLC
Entity type:Organization
Organization Name:KALENA SMITH-FULWILEY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KALENA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH-FULWILEY
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:904-476-9064
Mailing Address - Street 1:15597 SPOTTED SADDLE CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-7984
Mailing Address - Country:US
Mailing Address - Phone:904-476-9064
Mailing Address - Fax:
Practice Address - Street 1:422 NEW BERLIN RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-3827
Practice Address - Country:US
Practice Address - Phone:904-269-0886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-16
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH12125251S00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010404400Medicaid