Healthcare Provider Details

I. General information

NPI: 1033542212
Provider Name (Legal Business Name): KELLI TAYLOR PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLI MCCORMICK

II. Dates (important events)

Enumeration Date: 08/12/2013
Last Update Date: 10/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1587 DELL AVE # 320943
CAMPBELL CA
95008-6903
US

IV. Provider business mailing address

PO BOX 320943
LOS GATOS CA
95032-0115
US

V. Phone/Fax

Practice location:
  • Phone: 408-425-3257
  • Fax:
Mailing address:
  • Phone: 408-425-3257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number30414
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: