Provider Demographics
NPI:1336696772
Name:KELLY, KATHY ANN (LMFT)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2811 F ST APT 19
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-3765
Mailing Address - Country:US
Mailing Address - Phone:916-218-5373
Mailing Address - Fax:
Practice Address - Street 1:107 WOODBINE PL
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-2912
Practice Address - Country:US
Practice Address - Phone:800-446-8253
Practice Address - Fax:903-234-1639
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53476106H00000X
TX203963106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist