Provider Demographics
NPI:1124909429
Name:VANDEVENTER, KELLY ROSE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ROSE
Last Name:VANDEVENTER
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 1:11439 CITRA CIR APT 307
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-5965
Mailing Address - Country:US
Mailing Address - Phone:800-875-1871
Mailing Address - Fax:800-875-1871
Practice Address - Street 1:11983 TAMIAMI TRL N # 121
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-1603
Practice Address - Country:US
Practice Address - Phone:800-975-1871
Practice Address - Fax:800-875-1871
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-11
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB1380660106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty