Provider Demographics
NPI:1801430244
Name:KELLEMS, IVETTE MARTHA
Entity type:Individual
Prefix:
First Name:IVETTE
Middle Name:MARTHA
Last Name:KELLEMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:IVETTE
Other - Middle Name:
Other - Last Name:PORRAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RMFTI
Mailing Address - Street 1:2471 SW 10TH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33135-4800
Mailing Address - Country:US
Mailing Address - Phone:305-338-4848
Mailing Address - Fax:
Practice Address - Street 1:654 NE 9TH PL
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4934
Practice Address - Country:US
Practice Address - Phone:305-248-3488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMT2498101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIMT2498OtherDEPARTMENT OF HEALTH