Provider Demographics
NPI:1871978247
Name:MCSORLEY, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MCSORLEY
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 1:525 NE 30TH ST
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33334-2054
Mailing Address - Country:US
Mailing Address - Phone:314-853-5652
Mailing Address - Fax:954-337-3125
Practice Address - Street 1:525 NE 30TH ST
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33334-2054
Practice Address - Country:US
Practice Address - Phone:314-853-5652
Practice Address - Fax:954-337-3125
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9099103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical