Provider Demographics
NPI:1639738131
Name:YANG, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:YANG
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 1:1088 S LA BREA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-6905
Mailing Address - Country:US
Mailing Address - Phone:323-295-0262
Mailing Address - Fax:
Practice Address - Street 1:1088 S LA BREA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019-6905
Practice Address - Country:US
Practice Address - Phone:323-295-0262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1518097229Medicaid