Provider Demographics
NPI:1801560180
Name:EDYBURN, KELLY LEIGH (PHD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:LEIGH
Last Name:EDYBURN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8711 MACARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-4000
Mailing Address - Country:US
Mailing Address - Phone:510-428-3556
Mailing Address - Fax:
Practice Address - Street 1:8711 MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-4000
Practice Address - Country:US
Practice Address - Phone:510-428-3556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY33603103TC2200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent