Provider Demographics
NPI:1568665719
Name:KILLELEA, KEVIN M
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:M
Last Name:KILLELEA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 NORTHGATE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-3696
Mailing Address - Country:US
Mailing Address - Phone:415-419-9641
Mailing Address - Fax:
Practice Address - Street 1:555 NORTHGATE DR STE 100
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-3696
Practice Address - Country:US
Practice Address - Phone:415-419-9641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor