Provider Demographics
NPI:1548590854
Name:KELLY, AMBER RAE (LCSW)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:RAE
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 NW 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601-5291
Mailing Address - Country:US
Mailing Address - Phone:352-219-5723
Mailing Address - Fax:
Practice Address - Street 1:4300 SW 13TH ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-4006
Practice Address - Country:US
Practice Address - Phone:352-374-5600
Practice Address - Fax:352-374-5608
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-08
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
FL98251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker