Provider Demographics
NPI:1922387661
Name:KELVIN, CYNTHIA MARIE
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:MARIE
Last Name:KELVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:CYNTHIA
Other - Middle Name:MARIE
Other - Last Name:HOLLOWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5242 KESTER AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-4085
Mailing Address - Country:US
Mailing Address - Phone:818-277-9815
Mailing Address - Fax:
Practice Address - Street 1:6842 VAN NUYS BLVD
Practice Address - Street 2:6TH FLOOR
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-4650
Practice Address - Country:US
Practice Address - Phone:818-901-4830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-12
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CA2012665103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty