Healthcare Provider Details

I. General information

NPI: 1083287957
Provider Name (Legal Business Name): MAYA KELLY PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15409 DICKENS ST
SHERMAN OAKS CA
91403-3009
US

IV. Provider business mailing address

5776 FAIRHAVEN AVE
WOODLAND HILLS CA
91367-3927
US

V. Phone/Fax

Practice location:
  • Phone: 818-986-4362
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLEP3257
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: