Provider Demographics
NPI:1396052429
Name:MANCIA, KELLY STAPENHORST
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:STAPENHORST
Last Name:MANCIA
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 1:2441 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-1324
Mailing Address - Country:US
Mailing Address - Phone:415-346-6380
Mailing Address - Fax:415-346-1058
Practice Address - Street 1:710 S BROADWAY
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-5294
Practice Address - Country:US
Practice Address - Phone:925-295-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA30114103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health