Provider Demographics
NPI:1891191300
Name:KELLY, LISA
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:KELLY
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 1:6833 STOCKTON BLVD STE 485
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-2376
Mailing Address - Country:US
Mailing Address - Phone:916-394-0800
Mailing Address - Fax:
Practice Address - Street 1:8113 HAGUE WAY
Practice Address - Street 2:
Practice Address - City:ELVERTA
Practice Address - State:CA
Practice Address - Zip Code:95626-9740
Practice Address - Country:US
Practice Address - Phone:916-216-6393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-10
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105332106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist