Healthcare Provider Details

I. General information

NPI: 1336607688
Provider Name (Legal Business Name): KELLY RAUCH PHD, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W CHAPMAN AVE STE 200
ORANGE CA
92866-1418
US

IV. Provider business mailing address

PO BOX 3340
TUSTIN CA
92781-3340
US

V. Phone/Fax

Practice location:
  • Phone: 855-750-5010
  • Fax:
Mailing address:
  • Phone: 949-569-9173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number110974
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: