Healthcare Provider Details

I. General information

NPI: 1992904494
Provider Name (Legal Business Name): KELLY M HINES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 08/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 COOLIDGE AVE
OAKLAND CA
94602-3311
US

IV. Provider business mailing address

1526 E 31ST ST A
OAKLAND CA
94602-1061
US

V. Phone/Fax

Practice location:
  • Phone: 510-482-2244
  • Fax: 510-488-1960
Mailing address:
  • Phone: 415-373-8593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401012104
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number59429
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: