Provider Demographics
NPI:1417637729
Name:BRETT, KELLY
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:BRETT
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 1:1083 RUBY CT
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-2837
Mailing Address - Country:US
Mailing Address - Phone:760-214-5016
Mailing Address - Fax:
Practice Address - Street 1:STE 300
Practice Address - Street 2:312 S CEDROS AVE
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-1943
Practice Address - Country:US
Practice Address - Phone:858-877-1574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-20
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66125225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist