Healthcare Provider Details

I. General information

NPI: 1700638301
Provider Name (Legal Business Name): KELSEY COMPTON LEP #4181
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2024
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 W BONITA AVE STE 202
SAN DIMAS CA
91773-2543
US

IV. Provider business mailing address

300 E BONITA AVE UNIT 74
SAN DIMAS CA
91773-6102
US

V. Phone/Fax

Practice location:
  • Phone: 909-480-1834
  • Fax:
Mailing address:
  • Phone: 909-480-1834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number4181
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: