Provider Demographics
NPI:1639556673
Name:KELLEMS, ANDY BURL II (CADC)
Entity type:Individual
Prefix:
First Name:ANDY
Middle Name:BURL
Last Name:KELLEMS
Suffix:II
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:21062 BROOKHURST ST STE 201
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-7404
Mailing Address - Country:US
Mailing Address - Phone:714-964-6730
Mailing Address - Fax:714-964-4382
Practice Address - Street 1:3151 AIRWAY AVE STE F107
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4623
Practice Address - Country:US
Practice Address - Phone:714-964-6730
Practice Address - Fax:714-964-4382
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA081486101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA081486OtherCAADE