Healthcare Provider Details

I. General information

NPI: 1346567773
Provider Name (Legal Business Name): KELLY LEWALLEN MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2010
Last Update Date: 04/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44672 MONTEREY AVE
PALM DESERT CA
92260-3326
US

IV. Provider business mailing address

PO BOX 6753
LA QUINTA CA
92248-6753
US

V. Phone/Fax

Practice location:
  • Phone: 760-777-7720
  • Fax:
Mailing address:
  • Phone: 760-777-7720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number37832
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: