Provider Demographics
NPI:1659003473
Name:TAVENNER, KELLY ROCHELLE (LMFT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ROCHELLE
Last Name:TAVENNER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23161 MILL CREEK DR STE 230
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-7935
Mailing Address - Country:US
Mailing Address - Phone:949-264-5350
Mailing Address - Fax:949-221-6939
Practice Address - Street 1:23161 MILL CREEK DR STE 230
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-7935
Practice Address - Country:US
Practice Address - Phone:949-264-5350
Practice Address - Fax:949-221-6939
Is Sole Proprietor?:No
Enumeration Date:2022-06-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA146902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist