Healthcare Provider Details

I. General information

NPI: 1417047069
Provider Name (Legal Business Name): ANTHONY DESANTO-KELLY LICENSE PYSCH TECH 3
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 N LAKEWOOD BLVD
LONG BEACH CA
90808-1736
US

IV. Provider business mailing address

12857 FREDERICK ST APT 304
MORENO VALLEY CA
92553-4502
US

V. Phone/Fax

Practice location:
  • Phone: 562-570-7119
  • Fax:
Mailing address:
  • Phone: 951-653-3141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT24452
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: