Provider Demographics
NPI:1821745498
Name:KELLY, ANGELINE (AMFT)
Entity type:Individual
Prefix:
First Name:ANGELINE
Middle Name:
Last Name:KELLY
Suffix:
Gender:
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 PHILLIPS AVE
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-4829
Mailing Address - Country:US
Mailing Address - Phone:707-494-7311
Mailing Address - Fax:
Practice Address - Street 1:1006 PHILLIPS AVE
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-4829
Practice Address - Country:US
Practice Address - Phone:707-494-7311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-03
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA136742106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist