Healthcare Provider Details

I. General information

NPI: 1164626339
Provider Name (Legal Business Name): KELLY KIMBERLY HANZY BA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY KIMBERLY ROGERS

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3065 FREEPORT BLVD STE 11
SACRAMENTO CA
95818-4347
US

IV. Provider business mailing address

PO BOX 348056
SACRAMENTO CA
95834-8056
US

V. Phone/Fax

Practice location:
  • Phone: 916-767-1312
  • Fax:
Mailing address:
  • Phone: 510-323-5343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number137403
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: