Provider Demographics
NPI:1134655566
Name:SAETEURN, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SAETEURN
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 1:2967 MADELINE ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-3345
Mailing Address - Country:US
Mailing Address - Phone:510-570-5004
Mailing Address - Fax:
Practice Address - Street 1:2744 E 11TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-1440
Practice Address - Country:US
Practice Address - Phone:510-829-2381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-04
Last Update Date:2022-07-26
Deactivation Date:2018-09-14
Deactivation Code:
Reactivation Date:2022-06-27
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA104877390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health