Provider Demographics
NPI:1164548517
Name:KELLY-ADEGBOLA, KYELUNYE
Entity Type:Individual
Prefix:
First Name:KYELUNYE
Middle Name:
Last Name:KELLY-ADEGBOLA
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 1:2520 BALBOA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-5021
Mailing Address - Country:US
Mailing Address - Phone:619-266-4883
Mailing Address - Fax:
Practice Address - Street 1:3401 CLAIREMONT DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-5938
Practice Address - Country:US
Practice Address - Phone:858-490-3416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50463106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist