Provider Demographics
NPI:1629592340
Name:KELLEY, DONTE' LAVELL
Entity Type:Individual
Prefix:
First Name:DONTE'
Middle Name:LAVELL
Last Name:KELLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DONTI
Other - Middle Name:
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1180 W MAHALO PL UNIT B
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90220-5443
Mailing Address - Country:US
Mailing Address - Phone:310-868-5379
Mailing Address - Fax:
Practice Address - Street 1:1180 W MAHALO PL UNIT B
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90220-5443
Practice Address - Country:US
Practice Address - Phone:310-868-5379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CAMPSS-JLOTNC175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator