Provider Demographics
NPI:1477015014
Name:TACUNAN, KELLY M
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:TACUNAN
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 1:3117 S FRANCISCO WAY
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-5315
Mailing Address - Country:US
Mailing Address - Phone:510-730-6723
Mailing Address - Fax:
Practice Address - Street 1:3104 DELTA FAIR BLVD
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-4001
Practice Address - Country:US
Practice Address - Phone:818-345-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF3584527106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician