Healthcare Provider Details

I. General information

NPI: 1043550130
Provider Name (Legal Business Name): KEVIN KELLEY L.M.F.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2013
Last Update Date: 02/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 BEVERLY BLVD
LOS ANGELES CA
90057-2220
US

IV. Provider business mailing address

2330 BEVERLY BLVD
LOS ANGELES CA
90057-2220
US

V. Phone/Fax

Practice location:
  • Phone: 213-381-0534
  • Fax:
Mailing address:
  • Phone: 213-381-0534
  • Fax: 213-748-2432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 47853
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: