Provider Demographics
NPI:1528592599
Name:PARKER, KELLY (LMFT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PARKER
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 1:995 GATEWAY CENTER WAY STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4550
Mailing Address - Country:US
Mailing Address - Phone:303-552-8463
Mailing Address - Fax:
Practice Address - Street 1:1260 MORENA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3850
Practice Address - Country:US
Practice Address - Phone:619-398-0355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF89871106H00000X
CA120200106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist