Healthcare Provider Details

I. General information

NPI: 1376078006
Provider Name (Legal Business Name): KELSEY ERNESTINE STEVENS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8950 VILLA LA JOLLA DR STE C230
LA JOLLA CA
92037-1712
US

IV. Provider business mailing address

8950 VILLA LA JOLLA DR STE C230
LA JOLLA CA
92037-1712
US

V. Phone/Fax

Practice location:
  • Phone: 925-282-1778
  • Fax: 415-296-5299
Mailing address:
  • Phone: 925-282-1778
  • Fax: 415-296-5299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA166599
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA166599
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: