Healthcare Provider Details

I. General information

NPI: 1396498077
Provider Name (Legal Business Name): KELSEY NICOLE TUTT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3745 LONG BEACH BLVD STE 100
LONG BEACH CA
90807-3340
US

IV. Provider business mailing address

12712 HEACOCK ST STE 3
MORENO VALLEY CA
92553-3037
US

V. Phone/Fax

Practice location:
  • Phone: 310-787-9334
  • Fax:
Mailing address:
  • Phone: 951-550-0039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: