Provider Demographics
NPI:1740321454
Name:KING, KELLI ANN (MFT)
Entity type:Individual
Prefix:MS
First Name:KELLI
Middle Name:ANN
Last Name:KING
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2937 VENEMAN AVE
Mailing Address - Street 2:# A117
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-0638
Mailing Address - Country:US
Mailing Address - Phone:209-527-1185
Mailing Address - Fax:209-527-1186
Practice Address - Street 1:2937 VENEMAN AVE
Practice Address - Street 2:# A117
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-0638
Practice Address - Country:US
Practice Address - Phone:209-527-1185
Practice Address - Fax:209-527-1186
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC42864106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist