Provider Demographics
NPI:1508059080
Name:KELLY, KEVIN THOMAS (PHD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:THOMAS
Last Name:KELLY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:598 COCHRANE AVE
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-5621
Mailing Address - Country:US
Mailing Address - Phone:707-463-1447
Mailing Address - Fax:866-204-9690
Practice Address - Street 1:598 COCHRANE AVE
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5621
Practice Address - Country:US
Practice Address - Phone:707-463-1447
Practice Address - Fax:866-204-9690
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9275103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA00PL92750OtherBLUE SHIELD UIC #
CA7809105OtherBLUE CROSS PIN
CAPA0092759OtherMEDI-CAL
CA#00PL92750OtherBLUE SHIELD SUBMITTER
CAPSY00009275OtherBLUE CROSS
CAPA0092759OtherMEDI-CAL