Provider Demographics
NPI:1740380633
Name:KELLY, KIM ERIN (MA, LMFT, LPAT)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:ERIN
Last Name:KELLY
Suffix:
Gender:F
Credentials:MA, LMFT, LPAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 S JUNIPER ST # 115
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-4924
Mailing Address - Country:US
Mailing Address - Phone:760-420-5439
Mailing Address - Fax:
Practice Address - Street 1:333 S JUNIPER ST
Practice Address - Street 2:#115
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4924
Practice Address - Country:US
Practice Address - Phone:760-420-5439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4067101YP2500X
CAMFC48966106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional