Healthcare Provider Details

I. General information

NPI: 1730983891
Provider Name (Legal Business Name): SAMUEL DAVID KELLAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2025
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 E BELLEVUE AVE
SANTA ROSA CA
95407-2764
US

IV. Provider business mailing address

180 GOLF COURSE DR APT 150
ROHNERT PARK CA
94928-4914
US

V. Phone/Fax

Practice location:
  • Phone: 707-542-3671
  • Fax:
Mailing address:
  • Phone: 530-526-4113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number230146968
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: