Provider Demographics
NPI:1760197396
Name:MCGILL, KILEY ANN
Entity Type:Individual
Prefix:
First Name:KILEY
Middle Name:ANN
Last Name:MCGILL
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 1:838 9TH ST APT 5
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-1536
Mailing Address - Country:US
Mailing Address - Phone:310-845-5453
Mailing Address - Fax:
Practice Address - Street 1:31450 BROAD BEACH RD
Practice Address - Street 2:
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-2669
Practice Address - Country:US
Practice Address - Phone:310-881-8457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA124341106H00000X
CA141934106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist