Provider Demographics
NPI:1265226427
Name:KELLEY, ELIZABETH CHRISTINE (CST-T, CMT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:CHRISTINE
Last Name:KELLEY
Suffix:
Gender:
Credentials:CST-T, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 CALLISTO LN
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9656
Mailing Address - Country:US
Mailing Address - Phone:805-674-1307
Mailing Address - Fax:
Practice Address - Street 1:531 MARSH ST STE A
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3967
Practice Address - Country:US
Practice Address - Phone:805-674-1307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-04
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X, 226300000X, 374J00000X, 261QH0100X
CA31897225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No171400000XOther Service ProvidersHealth & Wellness Coach
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist
No374J00000XNursing Service Related ProvidersDoula