Healthcare Provider Details

I. General information

NPI: 1285102855
Provider Name (Legal Business Name): KELLIANN LIVELY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2018
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date: 04/13/2024
Reactivation Date: 10/16/2025

III. Provider practice location address

222 S HARBOR BLVD
ANAHEIM CA
92805-3700
US

IV. Provider business mailing address

222 S HARBOR BLVD
ANAHEIM CA
92805-3700
US

V. Phone/Fax

Practice location:
  • Phone: 714-871-5646
  • Fax:
Mailing address:
  • Phone: 714-871-5646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: