Provider Demographics
NPI:1316596133
Name:BETTIS TRUJILLO, KELSEY (LCSW107310)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:BETTIS TRUJILLO
Suffix:
Gender:F
Credentials:LCSW107310
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 S BEACON ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-4324
Mailing Address - Country:US
Mailing Address - Phone:310-514-4940
Mailing Address - Fax:
Practice Address - Street 1:2309 190TH ST
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-5206
Practice Address - Country:US
Practice Address - Phone:310-339-6584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical