Provider Demographics
NPI:1851544340
Name:MC HENRY, KELLY MARIE (MSW)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:MARIE
Last Name:MC HENRY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4950 SANTA CRUZ AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-3311
Mailing Address - Country:US
Mailing Address - Phone:619-552-8585
Mailing Address - Fax:
Practice Address - Street 1:1250 6TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-4368
Practice Address - Country:US
Practice Address - Phone:619-515-2430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA296891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical