1750703500 NPI number — GELSY AMORES HAWKINS

Table of content: KRYSTLE ELIZABETH HAVILAND LPC, CSAC, ICS (NPI 1750653580)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750703500 NPI number — GELSY AMORES HAWKINS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAWKINS
Provider First Name:
GELSY
Provider Middle Name:
AMORES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750703500
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5136 27TH ST SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEHIGH ACRES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33973-6615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-970-6121
Provider Business Mailing Address Fax Number:
239-491-3057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5136 27TH ST SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEHIGH ACRES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33973-6615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-970-6121
Provider Business Practice Location Address Fax Number:
239-491-3057
Provider Enumeration Date:
01/14/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2355S0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 014263000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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