Healthcare Provider Details

I. General information

NPI: 1720433162
Provider Name (Legal Business Name): BRITTANY LYNNE KELLY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRITTANY LYNNE PORTER

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 03/07/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 JOANN ST
COSTA MESA CA
92626-6455
US

IV. Provider business mailing address

960 N TUSTIN ST STE 113
ORANGE CA
92867-5956
US

V. Phone/Fax

Practice location:
  • Phone: 949-631-9041
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number95143
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: