Provider Demographics
NPI:1316359060
Name:KELLY, KAYLA ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:KAYLA
Middle Name:ELIZABETH
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KAYLA
Other - Middle Name:ELIZABETH
Other - Last Name:LUTTMERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3255 WING ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-4638
Mailing Address - Country:US
Mailing Address - Phone:619-840-9195
Mailing Address - Fax:
Practice Address - Street 1:1870 CORDELL CT STE 101
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-0915
Practice Address - Country:US
Practice Address - Phone:619-448-9700
Practice Address - Fax:619-448-9711
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-29
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102656106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist