Provider Demographics
NPI:1720594468
Name:WALL, KELLI O'ROURKE (LMFT)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:O'ROURKE
Last Name:WALL
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:ANNE
Other - Last Name:O'ROURKE-WALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:PO BOX 5554
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94581-0554
Mailing Address - Country:US
Mailing Address - Phone:707-266-6309
Mailing Address - Fax:
Practice Address - Street 1:1032 WALNUT ST
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94559-2210
Practice Address - Country:US
Practice Address - Phone:707-266-6309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-18
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF95403106H00000X
CA114085106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist