Provider Demographics
NPI:1194819797
Name:KELLEY, DIANE RENEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:RENEE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 N SEPULVEDA BLVD
Mailing Address - Street 2:SUITE H
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-5965
Mailing Address - Country:US
Mailing Address - Phone:310-559-3164
Mailing Address - Fax:310-802-8856
Practice Address - Street 1:1021 N SEPULVEDA BLVD
Practice Address - Street 2:SUITE H
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-5965
Practice Address - Country:US
Practice Address - Phone:310-559-3164
Practice Address - Fax:310-802-8856
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12962103TC0700X
CAMFC5783106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR16255Medicare UPIN
CACP12962AMedicare ID - Type UnspecifiedPROVIDER NUMBER