Healthcare Provider Details

I. General information

NPI: 1073637013
Provider Name (Legal Business Name): KELLY ANN RUOTOLO LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 02/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28310 ROADSIDE DR STE 202
AGOURA HILLS CA
91301-4958
US

IV. Provider business mailing address

5739 KANAN RD #613
AGOURA HILLS CA
91301-1601
US

V. Phone/Fax

Practice location:
  • Phone: 818-421-7518
  • Fax:
Mailing address:
  • Phone: 805-652-6727
  • Fax: 805-652-6026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number88993
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: