Provider Demographics
NPI:1326447897
Name:KELLEY, KIMBERLY (LCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:MAHON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:619-515-2300
Mailing Address - Fax:
Practice Address - Street 1:823 GATEWAY CENTER WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-4541
Practice Address - Country:US
Practice Address - Phone:619-515-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-20
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.099235871041C0700X
CA978881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical