Provider Demographics
NPI:1508649906
Name:DOUGLAS, KELLY LEININGER (LMFT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LEININGER
Last Name:DOUGLAS
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 1:30 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95030-5837
Mailing Address - Country:US
Mailing Address - Phone:408-348-2230
Mailing Address - Fax:
Practice Address - Street 1:30 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95030-5837
Practice Address - Country:US
Practice Address - Phone:408-348-2230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA140658106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist