Provider Demographics
NPI:1770140600
Name:FOREMAN, KELLY MARIE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:FOREMAN
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 1:500 W HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:FRENCH CAMP
Mailing Address - State:CA
Mailing Address - Zip Code:95231-9693
Mailing Address - Country:US
Mailing Address - Phone:209-468-6013
Mailing Address - Fax:209-468-7032
Practice Address - Street 1:500 W HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:FRENCH CAMP
Practice Address - State:CA
Practice Address - Zip Code:95231-9693
Practice Address - Country:US
Practice Address - Phone:209-468-6013
Practice Address - Fax:209-468-7032
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-27
Last Update Date:2019-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390002EN3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB7155385OtherDMV