Provider Demographics
NPI:1700638301
Name:COMPTON, KELSEY (LEP #4181)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:COMPTON
Suffix:
Gender:F
Credentials:LEP #4181
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E BONITA AVE UNIT 74
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-6102
Mailing Address - Country:US
Mailing Address - Phone:909-480-1834
Mailing Address - Fax:
Practice Address - Street 1:425 W BONITA AVE STE 202
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2543
Practice Address - Country:US
Practice Address - Phone:909-480-1834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-05
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4181103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool