Provider Demographics
NPI:1659009389
Name:KELLEY, DEMETRI RASHAD
Entity Type:Individual
Prefix:
First Name:DEMETRI
Middle Name:RASHAD
Last Name:KELLEY
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 1:16258 LADYBIRD WAY
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-5828
Mailing Address - Country:US
Mailing Address - Phone:760-605-4778
Mailing Address - Fax:
Practice Address - Street 1:11519 CARLISLE PL
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7233
Practice Address - Country:US
Practice Address - Phone:909-484-7259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty