Provider Demographics
NPI:1629512686
Name:YONSTON, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:YONSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:YOUNT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EDS
Mailing Address - Street 1:3005 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-6029
Mailing Address - Country:US
Mailing Address - Phone:858-437-4004
Mailing Address - Fax:
Practice Address - Street 1:3005 STATE ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-6029
Practice Address - Country:US
Practice Address - Phone:858-437-4004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-10
Last Update Date:2016-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA160147038103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool