Provider Demographics
NPI:1629445085
Name:FERREIRA, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FERREIRA
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 1:715 PORT ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CROCKETT
Mailing Address - State:CA
Mailing Address - Zip Code:94525-1120
Mailing Address - Country:US
Mailing Address - Phone:510-860-6324
Mailing Address - Fax:
Practice Address - Street 1:715 PORT ST APT 2
Practice Address - Street 2:
Practice Address - City:CROCKETT
Practice Address - State:CA
Practice Address - Zip Code:94525-1120
Practice Address - Country:US
Practice Address - Phone:510-860-6324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC2080275324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC2080275Medicaid