Provider Demographics
NPI:1013416429
Name:VALLECILLO, KELLEY ANNE
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:ANNE
Last Name:VALLECILLO
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 1:1400 N JOHNSON AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-1651
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7625 MESA COLLEGE DR STE 115
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-5354
Practice Address - Country:US
Practice Address - Phone:858-277-4633
Practice Address - Fax:858-277-4933
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)