Provider Demographics
NPI:1376901413
Name:WOLFE, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WOLFE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 921
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92822-0921
Mailing Address - Country:US
Mailing Address - Phone:805-720-6859
Mailing Address - Fax:
Practice Address - Street 1:729 MULBERRY AVE
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-6456
Practice Address - Country:US
Practice Address - Phone:805-720-6859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15983225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics