Provider Demographics
NPI:1225112055
Name:PROTHERO, KELLY D (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:D
Last Name:PROTHERO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 LAUREL PL
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2012
Mailing Address - Country:US
Mailing Address - Phone:415-747-8903
Mailing Address - Fax:
Practice Address - Street 1:100 TAMAL PLZ
Practice Address - Street 2:SUITE 195
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1125
Practice Address - Country:US
Practice Address - Phone:415-497-8322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 263691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical