Provider Demographics
NPI:1073738894
Name:KELLEY, MICHAEL MCIVER
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:MCIVER
Last Name:KELLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2432 3RD ST REAR
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-3603
Mailing Address - Country:US
Mailing Address - Phone:310-633-0931
Mailing Address - Fax:
Practice Address - Street 1:14624 SHERMAN WAY STE 508
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-2289
Practice Address - Country:US
Practice Address - Phone:818-908-4990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50403106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist