MEDICARE: KELLY LEWALLEN MFT

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	106H00000X	Marriage & Family Therapist	37832	CA

General Provider Information

NPI Number	:	1346567773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY LEWALLEN MFT

Provider Business Mailing Address
First Line	:	PO BOX 6753
Second Line	:
City	:	LA QUINTA
State	:	CA
Zip	:	92248-6753
Country	:	US
Telephone Number	:	760-777-7720
Fax Number	:

Provider Business Practice Location Address
First Line	:	44672 MONTEREY AVE
Second Line	:
City	:	PALM DESERT
State	:	CA
Zip	:	92260-3326
Country	:	US
Telephone Number	:	760-777-7720
Fax Number	:

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

Provider Enumeration Date	:	04/25/2010
Last Update Date	:	04/25/2010

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