Healthcare Provider Details

I. General information

NPI: 1194306944
Provider Name (Legal Business Name): KELLY ALBONICO PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 SIERRA BLANCA
CEDAR CREST NM
87008-9445
US

IV. Provider business mailing address

36 SIERRA BLANCA
CEDAR CREST NM
87008-9445
US

V. Phone/Fax

Practice location:
  • Phone: 415-246-8530
  • Fax:
Mailing address:
  • Phone: 415-246-8530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: