Healthcare Provider Details

I. General information

NPI: 1104965060
Provider Name (Legal Business Name): KELLY C MCCOY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 ALAMEDA DE LAS PULGAS STE 200
SAN MATEO CA
94403-1293
US

IV. Provider business mailing address

1132 GODETIA DR APT 1
WOODSIDE CA
94062-4117
US

V. Phone/Fax

Practice location:
  • Phone: 650-573-2618
  • Fax: 650-522-9830
Mailing address:
  • Phone: 650-743-0116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: