Provider Demographics
NPI:1275663528
Name:ROSEKRANS, KELLY J
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:ROSEKRANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1913 SPEYER LN
Mailing Address - Street 2:UNIT A
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-4844
Mailing Address - Country:US
Mailing Address - Phone:323-250-2016
Mailing Address - Fax:
Practice Address - Street 1:934 HERMOSA AVE
Practice Address - Street 2:SUITE 11
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-4122
Practice Address - Country:US
Practice Address - Phone:323-250-2016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2015-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT50224106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist