Provider Demographics
NPI:1306384714
Name:LOEUTH, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LOEUTH
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:PO BOX 33568
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-3568
Mailing Address - Country:US
Mailing Address - Phone:552-237-1238
Mailing Address - Fax:619-374-7134
Practice Address - Street 1:530 E HERNDON AVE STE 105
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2990
Practice Address - Country:US
Practice Address - Phone:855-223-7123
Practice Address - Fax:619-374-7134
Is Sole Proprietor?:No
Enumeration Date:2017-02-06
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-23-66909103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician