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General NPI Number Information
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NPI Number | 1801931548
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Entity Type | Individual
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Provider Name | HEATHER LAKE KELLY PSYD
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Gender | Female
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Dates
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Enumeration Date | 02/20/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 800 BETHANY DR
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City | SCOTTS VALLEY
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State | CA
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Zip | 95066-2820
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Country | US
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Telephone | 831-438-3800
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Fax |
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Provider Business Mailing Address
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Address Line | 270 GASTON CIR
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City | SCOTTS VALLEY
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State | CA
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Zip | 95066-2823
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Country | US
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Telephone | 831-247-1490
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | PSY 18917
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License Number State | CA
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