Provider Demographics
NPI:1437522430
Name:BOARDMAN, KELLY (LMFT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BOARDMAN
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 1:510 S 2ND AVE STE 7
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-3017
Mailing Address - Country:US
Mailing Address - Phone:626-332-7788
Mailing Address - Fax:626-669-7481
Practice Address - Street 1:510 S 2ND AVE STE 7
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3017
Practice Address - Country:US
Practice Address - Phone:626-332-7788
Practice Address - Fax:626-974-8198
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-12
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA97551106H00000X
CALMFT97551106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist