Provider Demographics
NPI:1164626339
Name:HANZY, KELLY KIMBERLY (BA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:KIMBERLY
Last Name:HANZY
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:KIMBERLY
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 348056
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-8056
Mailing Address - Country:US
Mailing Address - Phone:510-323-5343
Mailing Address - Fax:
Practice Address - Street 1:3065 FREEPORT BLVD STE 11
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95818-4347
Practice Address - Country:US
Practice Address - Phone:916-767-1312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X, 101Y00000X
CA137403106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor