Healthcare Provider Details

I. General information

NPI: 1780359703
Provider Name (Legal Business Name): MRS. CRISSY CHANELL KELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2021
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 W BRIGGSMORE AVE STE I
MODESTO CA
95350-3839
US

IV. Provider business mailing address

2000 W BRIGGSMORE AVE STE I
MODESTO CA
95350-3839
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-1476
  • Fax: 209-526-1476
Mailing address:
  • Phone: 209-526-1476
  • Fax: 209-526-1476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: