Provider Demographics
NPI:1528230919
Name:KELLY HORTON, PSY.D.
Entity Type:Organization
Organization Name:KELLY HORTON, PSY.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HORTON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:707-362-0456
Mailing Address - Street 1:PO BOX 888
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-0088
Mailing Address - Country:US
Mailing Address - Phone:707-362-0456
Mailing Address - Fax:707-552-1050
Practice Address - Street 1:631 TENNESSEE ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-4432
Practice Address - Country:US
Practice Address - Phone:707-362-0456
Practice Address - Fax:707-552-1050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20970251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL209700Medicare PIN