Provider Demographics
NPI:1073753182
Name:LAUGHERY, KELLYE DEBRA LEE (MBA MA LMFT 49206)
Entity Type:Individual
Prefix:MS
First Name:KELLYE
Middle Name:DEBRA LEE
Last Name:LAUGHERY
Suffix:
Gender:F
Credentials:MBA MA LMFT 49206
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 375
Mailing Address - Street 2:
Mailing Address - City:RODEO
Mailing Address - State:NM
Mailing Address - Zip Code:88056-0375
Mailing Address - Country:US
Mailing Address - Phone:619-884-0601
Mailing Address - Fax:760-884-3475
Practice Address - Street 1:3625 RUFFIN RD STE 302
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123
Practice Address - Country:US
Practice Address - Phone:619-884-0601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-02
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49206106H00000X
CAIMF #57982106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1234567Medicaid
CA1073753182Medicaid
CA1234567Medicaid
CA1234567Medicare Oscar/Certification