Healthcare Provider Details

I. General information

NPI: 1104736990
Provider Name (Legal Business Name): KELLY JANINE ANDERSON SUDRC I #24481
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 N DATE ST
ESCONDIDO CA
92025-3405
US

IV. Provider business mailing address

24934 ABALAR WAY
RAMONA CA
92065-4649
US

V. Phone/Fax

Practice location:
  • Phone: 760-291-4788
  • Fax:
Mailing address:
  • Phone: 855-740-2487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number24481
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT262840842
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSSQTUFZB
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: