Provider Demographics
NPI:1184287989
Name:KELLEY, KIM LYNN
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:LYNN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 CALIFORNIA DRIVE
Mailing Address - Street 2:
Mailing Address - City:YOUNTVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94599-1418
Mailing Address - Country:US
Mailing Address - Phone:707-944-4797
Mailing Address - Fax:707-944-4590
Practice Address - Street 1:150 CALIFORNIA DRIVE
Practice Address - Street 2:
Practice Address - City:YOUNTVILLE
Practice Address - State:CA
Practice Address - Zip Code:94599-1418
Practice Address - Country:US
Practice Address - Phone:707-944-4797
Practice Address - Fax:707-944-4590
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66304104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty