Healthcare Provider Details

I. General information

NPI: 1306065032
Provider Name (Legal Business Name): KELLSIE ANN MICHAEL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7150 BROADWAY
LEMON GROVE CA
91945-1401
US

IV. Provider business mailing address

5005 TEXAS ST SUITE 203
SAN DIEGO CA
92108-3721
US

V. Phone/Fax

Practice location:
  • Phone: 619-906-4630
  • Fax:
Mailing address:
  • Phone: 619-692-0727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number24208
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: