Provider Demographics
NPI:1376067231
Name:THOMPSON, KELLY DAWN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:DAWN
Last Name:THOMPSON
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 1:3470 NATURE TRAIL CT
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-7364
Mailing Address - Country:US
Mailing Address - Phone:661-345-0036
Mailing Address - Fax:
Practice Address - Street 1:28693 OLD TOWN FRONT ST
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-2786
Practice Address - Country:US
Practice Address - Phone:951-395-1916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-01
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT1265071041C0700X
171M00000X
CA152301106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator