Provider Demographics
NPI:1528571825
Name:ONTIVEROS, KELLY CATHERINE (LICENSED MARRIAGE &)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:CATHERINE
Last Name:ONTIVEROS
Suffix:
Gender:F
Credentials:LICENSED MARRIAGE &
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2563 S VAL VISTA DR STE 108
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-6231
Mailing Address - Country:US
Mailing Address - Phone:602-690-8021
Mailing Address - Fax:
Practice Address - Street 1:8666 E. SAN ALBERTO DRIVE
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258
Practice Address - Country:US
Practice Address - Phone:602-544-6044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-08
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAMFT-5807T106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist