Provider Demographics
NPI:1689021453
Name:WHITECOTTON, KELLEY LYNN
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:LYNN
Last Name:WHITECOTTON
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 1:500 CROWN POINT CIR
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-9561
Mailing Address - Country:US
Mailing Address - Phone:530-470-2425
Mailing Address - Fax:
Practice Address - Street 1:500 CROWN POINT CIR
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945
Practice Address - Country:US
Practice Address - Phone:530-265-1437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-20
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAPT40257167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health