Provider Demographics
NPI:1447811773
Name:CANIZALES, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CANIZALES
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 1:163 STERLING SPRINGS LN
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-3856
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 ADVANCE PT
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-3422
Practice Address - Country:US
Practice Address - Phone:386-627-1058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC524504906340OtherDRIVERS LICENSE