Provider Demographics
NPI:1821402132
Name:KELLY, SONYA MARIA (PHD)
Entity Type:Individual
Prefix:DR
First Name:SONYA
Middle Name:MARIA
Last Name:KELLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:S.
Other - Middle Name:M
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:P.O. BOX 156
Mailing Address - Street 2:
Mailing Address - City:COTATI
Mailing Address - State:CA
Mailing Address - Zip Code:94931
Mailing Address - Country:US
Mailing Address - Phone:707-321-6997
Mailing Address - Fax:707-664-9626
Practice Address - Street 1:3558 ROUND BARN BLVD, SUITE 200
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403
Practice Address - Country:US
Practice Address - Phone:707-292-6714
Practice Address - Fax:707-664-9626
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-13
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17700103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist