Provider Demographics
NPI:1902813389
Name:HORTON, KELLY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:HORTON
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:PO BOX 888
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-0088
Mailing Address - Country:US
Mailing Address - Phone:510-449-3545
Mailing Address - Fax:
Practice Address - Street 1:39675 CEDAR BLVD
Practice Address - Street 2:SUITE 240
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-5489
Practice Address - Country:US
Practice Address - Phone:510-449-3545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20970103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical