Healthcare Provider Details

I. General information

NPI: 1134545478
Provider Name (Legal Business Name): KELSEY SPYRKA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2014
Last Update Date: 10/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 IRWIN LN
SANTA ROSA CA
95401-5603
US

IV. Provider business mailing address

1385 MISSION ST SUITE 200
SAN FRANCISCO CA
94103-2623
US

V. Phone/Fax

Practice location:
  • Phone: 707-360-1500
  • Fax:
Mailing address:
  • Phone: 415-864-4002
  • Fax: 415-864-7093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number102336
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number102336
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number102336
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: