Healthcare Provider Details

I. General information

NPI: 1497391080
Provider Name (Legal Business Name): KALLEY HARTMAN LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 11/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 KALMUS DR STE M2
COSTA MESA CA
92626-5977
US

IV. Provider business mailing address

3400 AVENUE OF THE ARTS APT G308
COSTA MESA CA
92626-7633
US

V. Phone/Fax

Practice location:
  • Phone: 949-683-9007
  • Fax:
Mailing address:
  • Phone: 949-683-9007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number116491
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: