Provider Demographics
NPI:1932334802
Name:GAVIN-GARCIA, KELLY LAURIAN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LAURIAN
Last Name:GAVIN-GARCIA
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 1:962 CORYDON ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-5116
Mailing Address - Country:US
Mailing Address - Phone:619-301-0350
Mailing Address - Fax:
Practice Address - Street 1:962 CORYDON ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-5116
Practice Address - Country:US
Practice Address - Phone:619-301-0350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-21
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT 53865106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist