Provider Demographics
NPI:1356962583
Name:KEALA, LAUREL AMY (MS)
Entity type:Individual
Prefix:MS
First Name:LAUREL
Middle Name:AMY
Last Name:KEALA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 HAYES ST STE B3
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-2970
Mailing Address - Country:US
Mailing Address - Phone:707-297-9270
Mailing Address - Fax:
Practice Address - Street 1:1350 HAYES ST STE B3
Practice Address - Street 2:
Practice Address - City:BENICIA
Practice Address - State:CA
Practice Address - Zip Code:94510-2970
Practice Address - Country:US
Practice Address - Phone:707-297-9270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT113115106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist