Healthcare Provider Details

I. General information

NPI: 1093584666
Provider Name (Legal Business Name): KELLI DZAJKICH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/25/2023
Last Update Date: 12/25/2023
Certification Date: 12/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 DOVE ST
NEWPORT BEACH CA
92660-2840
US

IV. Provider business mailing address

1151 DOVE ST
NEWPORT BEACH CA
92660-2840
US

V. Phone/Fax

Practice location:
  • Phone: 949-998-3484
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: