Provider Demographics
NPI:1093078867
Name:KELLY, DEBRA J (MFT)
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:J
Last Name:KELLY
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:114 SOTOYOME ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4804
Mailing Address - Country:US
Mailing Address - Phone:707-569-0459
Mailing Address - Fax:707-570-3941
Practice Address - Street 1:114 SOTOYOME ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4804
Practice Address - Country:US
Practice Address - Phone:707-569-0459
Practice Address - Fax:707-570-3941
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC19530101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health