Provider Demographics
NPI:1164048815
Name:MCCAFFERTY, KELLY ELIZABETH (MS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH
Last Name:MCCAFFERTY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 S GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-4121
Mailing Address - Country:US
Mailing Address - Phone:714-667-7610
Mailing Address - Fax:714-667-7621
Practice Address - Street 1:1001 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-4121
Practice Address - Country:US
Practice Address - Phone:714-667-7610
Practice Address - Fax:714-667-7621
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist