Provider Demographics
NPI:1568501682
Name:KILCOYNE, KELLY M (LMFT)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:M
Last Name:KILCOYNE
Suffix:
Gender:M
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:PO BOX 1512
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401
Mailing Address - Country:US
Mailing Address - Phone:650-485-1512
Mailing Address - Fax:650-342-5678
Practice Address - Street 1:205 E 3RD AVE
Practice Address - Street 2:SUITE 207-C
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-4051
Practice Address - Country:US
Practice Address - Phone:650-485-1512
Practice Address - Fax:650-342-5678
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2015-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT51065106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist