Provider Demographics
NPI:1962439661
Name:CLOUGHERTY, KELLEE RAE (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLEE
Middle Name:RAE
Last Name:CLOUGHERTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:30101 TOWN CENTER DR STE 216
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-2065
Mailing Address - Country:US
Mailing Address - Phone:805-798-5100
Mailing Address - Fax:949-388-5125
Practice Address - Street 1:21632 WESLEY DR
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-8167
Practice Address - Country:US
Practice Address - Phone:949-499-5346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG793912084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG96675Medicare UPIN