Provider Demographics
NPI:1225186737
Name:KELLEY, KATHLEEN ANNE (MS, MFT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANNE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MS, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 HIGH DR
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-1730
Mailing Address - Country:US
Mailing Address - Phone:949-715-0344
Mailing Address - Fax:
Practice Address - Street 1:6117 BROCKTON AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2232
Practice Address - Country:US
Practice Address - Phone:951-686-0223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 21551101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health