Provider Demographics
NPI:1922474303
Name:KELLY, MARY ALICE (BA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ALICE
Last Name:KELLY
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7000 FRANKLIN BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-1865
Mailing Address - Country:US
Mailing Address - Phone:916-394-9195
Mailing Address - Fax:916-392-2827
Practice Address - Street 1:7000 FRANKLIN BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-1865
Practice Address - Country:US
Practice Address - Phone:916-394-9195
Practice Address - Fax:916-392-2827
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMA313-50-4187OtherMEDICARE