Provider Demographics
NPI:1861900458
Name:STEVENS, KELLY LANE (LMFT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LANE
Last Name:STEVENS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13453 N MAIN ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218
Mailing Address - Country:US
Mailing Address - Phone:904-773-4390
Mailing Address - Fax:941-621-7089
Practice Address - Street 1:13453 N MAIN ST STE 104
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-2773
Practice Address - Country:US
Practice Address - Phone:904-773-4390
Practice Address - Fax:941-621-7089
Is Sole Proprietor?:No
Enumeration Date:2018-01-17
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSG014OtherMEDICARE