Healthcare Provider Details

I. General information

NPI: 1629696265
Provider Name (Legal Business Name): KELSEY NICHOLE WEISS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2020
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 4TH ST STE 19
PETALUMA CA
94952-3072
US

IV. Provider business mailing address

PO BOX 593
VALLEY FORD CA
94972-0593
US

V. Phone/Fax

Practice location:
  • Phone: 707-840-5059
  • Fax:
Mailing address:
  • Phone: 206-817-6702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number146182
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: