Provider Demographics
NPI:1093882698
Name:O'BRYAN, KELLY A (PHD)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:A
Last Name:O'BRYAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25143 JACK RABBIT ACRES
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026-1267
Mailing Address - Country:US
Mailing Address - Phone:760-566-8648
Mailing Address - Fax:
Practice Address - Street 1:25143 JACK RABBIT ACRES
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92026-1267
Practice Address - Country:US
Practice Address - Phone:760-566-8648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA24966103T00000X
CAPSY24966103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY24966Medicaid