Provider Demographics
NPI:1578205001
Name:MCKELROY, BETZAIRA
Entity Type:Individual
Prefix:
First Name:BETZAIRA
Middle Name:
Last Name:MCKELROY
Suffix:
Gender:F
Credentials:
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 255
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:CA
Mailing Address - Zip Code:92325-0255
Mailing Address - Country:US
Mailing Address - Phone:951-269-8499
Mailing Address - Fax:
Practice Address - Street 1:24028 LAKE DR.
Practice Address - Street 2:
Practice Address - City:CRESTLINE
Practice Address - State:CA
Practice Address - Zip Code:92325
Practice Address - Country:US
Practice Address - Phone:909-338-3322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11142101YM0800X
CA131278106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health