Provider Demographics
NPI:1275918146
Name:WORSHAM, KELLISHIA T
Entity Type:Individual
Prefix:
First Name:KELLISHIA
Middle Name:T
Last Name:WORSHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLISHIA
Other - Middle Name:T
Other - Last Name:WORSHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:141 N ARROWHEAD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-1016
Mailing Address - Country:US
Mailing Address - Phone:909-963-5355
Mailing Address - Fax:
Practice Address - Street 1:222 N MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786
Practice Address - Country:US
Practice Address - Phone:909-727-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-21
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator