Provider Demographics
NPI:1154628634
Name:LAURA KELLISON, PSY,.D.
Entity Type:Organization
Organization Name:LAURA KELLISON, PSY,.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLISON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:707-364-9388
Mailing Address - Street 1:115 LIBERTY ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-2326
Mailing Address - Country:US
Mailing Address - Phone:707-364-9388
Mailing Address - Fax:
Practice Address - Street 1:115 LIBERTY ST
Practice Address - Street 2:SUITE 4
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2326
Practice Address - Country:US
Practice Address - Phone:707-364-9388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-18
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19863103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty