Provider Demographics
NPI:1891029005
Name:MINER-GANN, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MINER-GANN
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 1:844 OLD TUNNEL RD
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-8524
Mailing Address - Country:US
Mailing Address - Phone:530-273-4984
Mailing Address - Fax:
Practice Address - Street 1:844 OLD TUNNEL RD
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-8524
Practice Address - Country:US
Practice Address - Phone:530-273-4984
Practice Address - Fax:530-273-4573
Is Sole Proprietor?:No
Enumeration Date:2009-09-22
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC 70042FOtherSANTA CRUZ COUNTY MEDI-CAL PROVIDER #
CAFHC 70044FOtherSANTA CRUZ COUNTY MEDI-CAL PROVIDER #
CAZZZ91891ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#
CAZZZ91892ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#
CAZZZ92069ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#