Provider Demographics
NPI:1659544708
Name:KELL, SUSAN MARIE (PSYD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:KELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30713 RIVERSIDE DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-4714
Mailing Address - Country:US
Mailing Address - Phone:951-678-1642
Mailing Address - Fax:
Practice Address - Street 1:30713 RIVERSIDE DR
Practice Address - Street 2:SUITE 203
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4714
Practice Address - Country:US
Practice Address - Phone:951-678-1642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC39965101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health