Healthcare Provider Details

I. General information

NPI: 1639556673
Provider Name (Legal Business Name): ANDY BURL KELLEMS II CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2015
Last Update Date: 04/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3151 AIRWAY AVE STE F107
COSTA MESA CA
92626-4623
US

IV. Provider business mailing address

21062 BROOKHURST ST STE 201
HUNTINGTON BEACH CA
92646-7404
US

V. Phone/Fax

Practice location:
  • Phone: 714-964-6730
  • Fax: 714-964-4382
Mailing address:
  • Phone: 714-964-6730
  • Fax: 714-964-4382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number081486
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: