Provider Demographics
NPI:1528376506
Name:KELLY, STEVEN JAMES
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:JAMES
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:STEVEN
Other - Middle Name:JAMES
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFT
Mailing Address - Street 1:147 S RIVER ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-4551
Mailing Address - Country:US
Mailing Address - Phone:831-429-8601
Mailing Address - Fax:
Practice Address - Street 1:147 S RIVER ST
Practice Address - Street 2:SUITE 204
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4551
Practice Address - Country:US
Practice Address - Phone:831-429-8601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16945101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health