Provider Demographics
NPI:1205210945
Name:MCCANN, KELLY (MA, MFT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MCCANN
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2721 EAST PACIFIC COAST HIGHWAY
Mailing Address - Street 2:SUITE 209
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2721 EAST PACIFIC COAST HIGHWAY
Practice Address - Street 2:SUITE 209
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625
Practice Address - Country:US
Practice Address - Phone:949-385-2609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86054106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist