Provider Demographics
NPI:1891105193
Name:WARREN, KELLY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:WARREN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2447 PACIFIC COAST HWY STE 213
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-2714
Mailing Address - Country:US
Mailing Address - Phone:310-947-9279
Mailing Address - Fax:
Practice Address - Street 1:2447 PACIFIC COAST HWY STE 213
Practice Address - Street 2:
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-2714
Practice Address - Country:US
Practice Address - Phone:310-947-9279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-07
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27851103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist