Provider Demographics
NPI:1023235173
Name:KELLEY, MICHAEL (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:PHD
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 33
Mailing Address - Street 2:
Mailing Address - City:POPE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94567-0033
Mailing Address - Country:US
Mailing Address - Phone:707-337-0470
Mailing Address - Fax:
Practice Address - Street 1:553 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94559-3236
Practice Address - Country:US
Practice Address - Phone:707-337-0470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7743103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY7743OtherPSYCHOLOGY LICENSE
CA00PL77430Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER