Healthcare Provider Details

I. General information

NPI: 1962638510
Provider Name (Legal Business Name): KELLY R ZOLLO LPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 06/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12353 IMPERIAL HWY
NORWALK CA
90650-8305
US

IV. Provider business mailing address

12353 IMPERIAL HWY
NORWALK CA
90650-8305
US

V. Phone/Fax

Practice location:
  • Phone: 562-484-3385
  • Fax: 562-484-0269
Mailing address:
  • Phone: 562-484-3385
  • Fax: 562-484-0269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number30755
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: