Healthcare Provider Details

I. General information

NPI: 1326965104
Provider Name (Legal Business Name): KELLYE MICHELLE HOUCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17000 VENTURA BLVD STE 102
ENCINO CA
91316-4149
US

IV. Provider business mailing address

1785 W STATE ROUTE 89A STE 1D
SEDONA AZ
86336-5559
US

V. Phone/Fax

Practice location:
  • Phone: 928-371-3885
  • Fax:
Mailing address:
  • Phone: 928-371-3885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number14765
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number96145
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: