Provider Demographics
NPI:1760538896
Name:KELLISON, LAURA JS (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:JS
Last Name:KELLISON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 4TH ST
Mailing Address - Street 2:SUITES 32 AND 33
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-3043
Mailing Address - Country:US
Mailing Address - Phone:707-364-9388
Mailing Address - Fax:
Practice Address - Street 1:7 4TH ST
Practice Address - Street 2:SUITES 32 AND 33
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-3043
Practice Address - Country:US
Practice Address - Phone:707-364-9388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19863103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist