Provider Demographics
NPI:1295279453
Name:COLLINS, KELSEY LYNN
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:LYNN
Last Name:COLLINS
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 1:1621 AMBERWOOD DR APT B
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-1903
Mailing Address - Country:US
Mailing Address - Phone:951-456-2287
Mailing Address - Fax:
Practice Address - Street 1:1621 AMBERWOOD DR APT B
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-1903
Practice Address - Country:US
Practice Address - Phone:951-456-2287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-07
Last Update Date:2020-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT112953106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist