Provider Demographics
NPI:1700817202
Name:CONDON, KELLIE (PHD)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:CONDON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1288 MORRO ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6302
Mailing Address - Country:US
Mailing Address - Phone:805-543-1233
Mailing Address - Fax:
Practice Address - Street 1:1288 MORRO ST STE 200
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-6302
Practice Address - Country:US
Practice Address - Phone:805-543-1233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15802103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical