Healthcare Provider Details

I. General information

NPI: 1669916862
Provider Name (Legal Business Name): KELLY DORMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2016
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7200 BANCROFT AVE STE 133
OAKLAND CA
94605-2480
US

IV. Provider business mailing address

7200 BANCROFT AVE STE 133
OAKLAND CA
94605-2480
US

V. Phone/Fax

Practice location:
  • Phone: 510-553-8500
  • Fax:
Mailing address:
  • Phone: 510-553-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: