Provider Demographics
NPI:1265291546
Name:LOFTIS, KELLY R
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:LOFTIS
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:PO BOX 33432
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-3432
Mailing Address - Country:US
Mailing Address - Phone:858-848-0159
Mailing Address - Fax:
Practice Address - Street 1:8885 RIO SAN DIEGO DR STE 365
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1627
Practice Address - Country:US
Practice Address - Phone:858-848-0159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA121885106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist