MEDICARE: DR. KELLEY BRYAN GIN PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFC 38529	CA
2	103T00000X	Psychologist	20624	CA
3	103TC0700X	Clinical Psychologist	PSY 20624	CA

General Provider Information

NPI Number	:	1194870949
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLEY BRYAN GIN PSYD

Provider Business Mailing Address
First Line	:	2711 ALCATRAZ AVE STE 2
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94705-2726
Country	:	US
Telephone Number	:	510-219-7091
Fax Number	:	510-269-9031

Provider Business Practice Location Address
First Line	:	2711 ALCATRAZ AVE STE 2
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94705-2726
Country	:	US
Telephone Number	:	510-219-7091
Fax Number	:	510-269-9031

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	03/17/2018

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