Provider Demographics
NPI:1962187716
Name:CALDERON, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CALDERON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 NW 25TH ST STE 5E
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33172-1416
Mailing Address - Country:US
Mailing Address - Phone:888-527-8037
Mailing Address - Fax:
Practice Address - Street 1:12750 NW 17TH ST UNIT 216
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33182-1422
Practice Address - Country:US
Practice Address - Phone:888-527-8037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-273681106S00000X
FL1-24-73395103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician