Healthcare Provider Details

I. General information

NPI: 1144157074
Provider Name (Legal Business Name): LAILANI KETZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 W MAIN ST
SANTA MARIA CA
93458-9727
US

IV. Provider business mailing address

430 MOUNTAIN AVE STE 304
NEW PROVIDENCE NJ
07974-2731
US

V. Phone/Fax

Practice location:
  • Phone: 805-361-8290
  • Fax:
Mailing address:
  • Phone: 973-299-9954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: