Provider Demographics
NPI:1831324524
Name:YI, KELLY SOYONG (PSYCHOLOGIST)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:SOYONG
Last Name:YI
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4797 TELEGRAPH AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-2007
Mailing Address - Country:US
Mailing Address - Phone:510-698-2467
Mailing Address - Fax:
Practice Address - Street 1:4797 TELEGRAPH AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-2007
Practice Address - Country:US
Practice Address - Phone:510-698-2467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-25
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 24210103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical