Healthcare Provider Details

I. General information

NPI: 1689021453
Provider Name (Legal Business Name): MRS. KELLEY LYNN WHITECOTTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2016
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CROWN POINT CIR
GRASS VALLEY CA
95945
US

IV. Provider business mailing address

500 CROWN POINT CIR
GRASS VALLEY CA
95945-9561
US

V. Phone/Fax

Practice location:
  • Phone: 530-265-1437
  • Fax:
Mailing address:
  • Phone: 530-470-2425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT40257
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: