Provider Demographics
NPI:1366639080
Name:MAGDALENO, KELLY MICHELLE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHELLE
Last Name:MAGDALENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MICHELLE
Other - Last Name:PFREHM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8101 BAY AVE
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:93505-2695
Mailing Address - Country:US
Mailing Address - Phone:760-373-2979
Mailing Address - Fax:760-373-2980
Practice Address - Street 1:8101 BAY AVE
Practice Address - Street 2:
Practice Address - City:CALIFORNIA CITY
Practice Address - State:CA
Practice Address - Zip Code:93505-2695
Practice Address - Country:US
Practice Address - Phone:760-373-2979
Practice Address - Fax:760-373-2980
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor