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General NPI Number Information
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NPI Number | 1154628634
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Entity Type | Organization
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Legal Business Name | LAURA KELLISON, PSY,.D.
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Dates
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Enumeration Date | 02/18/2011
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Last Update Date | 02/18/2011
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Provider Practice Location Address
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Address Line | 115 LIBERTY ST SUITE 4
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City | PETALUMA
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State | CA
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Zip | 94952-2326
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Country | US
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Telephone | 707-364-9388
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Fax |
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Provider Business Mailing Address
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Address Line | 115 LIBERTY ST SUITE 4
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City | PETALUMA
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State | CA
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Zip | 94952-2326
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Country | US
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Telephone | 707-364-9388
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Fax |
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | LAURA KELLISON
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Credential | PSY.D.
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Telephone | 707-364-9388
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 19863
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License Number State | CA
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