Provider Demographics
NPI:1073637013
Name:RUOTOLO, KELLY ANN (LMFT)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANN
Last Name:RUOTOLO
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 1:5739 KANAN RD
Mailing Address - Street 2:#613
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-1601
Mailing Address - Country:US
Mailing Address - Phone:805-652-6727
Mailing Address - Fax:805-652-6026
Practice Address - Street 1:28310 ROADSIDE DR STE 202
Practice Address - Street 2:
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-4958
Practice Address - Country:US
Practice Address - Phone:818-421-7518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88993106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist