Provider Demographics
NPI:1801931548
Name:KELLY, HEATHER LAKE (PSYD)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:LAKE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 GASTON CIR
Mailing Address - Street 2:
Mailing Address - City:SCOTTS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95066-2823
Mailing Address - Country:US
Mailing Address - Phone:831-247-1490
Mailing Address - Fax:
Practice Address - Street 1:800 BETHANY DR
Practice Address - Street 2:
Practice Address - City:SCOTTS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95066-2820
Practice Address - Country:US
Practice Address - Phone:831-438-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 18917103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical