Provider Demographics
NPI:1073863304
Name:FELTON, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FELTON
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 1:1655 E 6TH ST
Mailing Address - Street 2:A5A, STE #117
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-1732
Mailing Address - Country:US
Mailing Address - Phone:951-735-5300
Mailing Address - Fax:951-735-9335
Practice Address - Street 1:1655 E 6TH ST
Practice Address - Street 2:A5A, STE #117
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-1732
Practice Address - Country:US
Practice Address - Phone:951-735-5300
Practice Address - Fax:951-735-9335
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CAASW37112101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor