Provider Demographics
NPI:1003278797
Name:KELLY, DEBRA A (MFT, BCBA)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:A
Last Name:KELLY
Suffix:
Gender:F
Credentials:MFT, BCBA
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:A
Other - Last Name:BANDY-KELLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MFT, BCBA
Mailing Address - Street 1:8787 COMPLEX DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1453
Mailing Address - Country:US
Mailing Address - Phone:197-971-0906
Mailing Address - Fax:858-444-8827
Practice Address - Street 1:29122 RANCHO VIEJO RD STE 206
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-1039
Practice Address - Country:US
Practice Address - Phone:949-335-0254
Practice Address - Fax:493-883-3109
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 35691106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA13810781OtherCAQH