Healthcare Provider Details

I. General information

NPI: 1487112561
Provider Name (Legal Business Name): KELLY NOBLE MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2019
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

829 SONOMA AVE
SANTA ROSA CA
95404-4757
US

IV. Provider business mailing address

PO BOX 9335
SANTA ROSA CA
95405-1335
US

V. Phone/Fax

Practice location:
  • Phone: 707-408-4392
  • Fax:
Mailing address:
  • Phone: 707-408-4392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number109543
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: