Healthcare Provider Details

I. General information

NPI: 1386867729
Provider Name (Legal Business Name): KELLY RICHARD THOMPSON CAARR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2169 ALLUVIAL AVE
CLOVIS CA
93611-6633
US

IV. Provider business mailing address

2169 ALLUVIAL AVE
CLOVIS CA
93611-6633
US

V. Phone/Fax

Practice location:
  • Phone: 559-297-1733
  • Fax:
Mailing address:
  • Phone: 559-297-1733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number02-054242
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: