Provider Demographics
NPI:1780012484
Name:KELLY, STEPHANIE LYN
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYN
Last Name:KELLY
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 1:4264 MABEL AVE
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-3547
Mailing Address - Country:US
Mailing Address - Phone:925-399-8075
Mailing Address - Fax:
Practice Address - Street 1:2258 CAMINO RAMON
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1353
Practice Address - Country:US
Practice Address - Phone:925-399-8075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT102784106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist