Provider Demographics
NPI:1073879623
Name:KELLY, RITA M
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:M
Last Name:KELLY
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 1:1200 WILSHIRE BLVD
Mailing Address - Street 2:SUITE500
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-1908
Mailing Address - Country:US
Mailing Address - Phone:213-481-7464
Mailing Address - Fax:213-481-7147
Practice Address - Street 1:1200 WILSHIRE BLVD
Practice Address - Street 2:SUITE500
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1908
Practice Address - Country:US
Practice Address - Phone:213-481-7464
Practice Address - Fax:213-481-7147
Is Sole Proprietor?:No
Enumeration Date:2012-04-09
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF67598106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist