Provider Demographics
NPI:1508353038
Name:MCCALL, KELLY MICHAEL
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHAEL
Last Name:MCCALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24302 TOLEDO LN
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-1935
Mailing Address - Country:US
Mailing Address - Phone:949-742-2121
Mailing Address - Fax:
Practice Address - Street 1:24302 TOLEDO LN
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-1935
Practice Address - Country:US
Practice Address - Phone:949-716-0956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-19
Last Update Date:2019-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
CA92112101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst