Provider Demographics
NPI:1942445887
Name:NIESS, KELLY M (MFTI 58694)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:NIESS
Suffix:
Gender:F
Credentials:MFTI 58694
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 MANOR PLZ
Mailing Address - Street 2:
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044-1839
Mailing Address - Country:US
Mailing Address - Phone:650-355-8787
Mailing Address - Fax:650-355-8780
Practice Address - Street 1:480 MANOR PLZ
Practice Address - Street 2:
Practice Address - City:PACIFICA
Practice Address - State:CA
Practice Address - Zip Code:94044-1839
Practice Address - Country:US
Practice Address - Phone:650-355-8787
Practice Address - Fax:650-355-8780
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-05
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFTI 58694106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist