Provider Demographics
NPI:1922765049
Name:KELLY, RACHAEL VICTORIA (PSR SPECIALIST, RBT)
Entity type:Individual
Prefix:MRS
First Name:RACHAEL
Middle Name:VICTORIA
Last Name:KELLY
Suffix:
Gender:F
Credentials:PSR SPECIALIST, RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14007 ZEPHERMOOR LN
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-5330
Mailing Address - Country:US
Mailing Address - Phone:321-320-0781
Mailing Address - Fax:
Practice Address - Street 1:518 PEACHTREE RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-6813
Practice Address - Country:US
Practice Address - Phone:321-320-0781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-23
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
FLRBT-22-198902106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No251B00000XAgenciesCase Management