Provider Demographics
NPI:1194854745
Name:LAY-RAITT, KELLY A (MFT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:LAY-RAITT
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:RAITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:PO BOX 18
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-0018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:776 S STATE ST STE 103
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5833
Practice Address - Country:US
Practice Address - Phone:707-463-4915
Practice Address - Fax:707-463-4517
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50696106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA50696OtherLMFT 50696