MEDICARE: DR. BARBARA H. KELLY PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PSY18148	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PSY18148	OTHER	CA	CA STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1043349152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BARBARA H. KELLY PHD

Provider Business Mailing Address
First Line	:	1810 AVENIDA DEL MUNDO
Second Line	:	UNIT 807
City	:	CORONADO
State	:	CA
Zip	:	92118-3003
Country	:	US
Telephone Number	:	619-890-8491
Fax Number	:	619-435-1456

Provider Business Practice Location Address
First Line	:	2645 1ST AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-6506
Country	:	US
Telephone Number	:	619-890-8491
Fax Number	:	619-435-1456

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	07/22/2014

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