MEDICARE: MRS. KELLY DANIELE MCDADE-MENDUS MFT

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	MFC42198	CA

General Provider Information

NPI Number	:	1215085527
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY DANIELE MCDADE-MENDUS MFT

Provider Business Mailing Address
First Line	:	7803 TOMMY DR APT 66
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92119-1795
Country	:	US
Telephone Number	:	619-698-4210
Fax Number	:	619-258-0676

Provider Business Practice Location Address
First Line	:	4926 LA CUENTA DR
Second Line	:	SUITE 200
City	:	SAN DIEGO
State	:	CA
Zip	:	92124-2609
Country	:	US
Telephone Number	:	619-303-2265
Fax Number	:	619-258-0676

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

Provider Enumeration Date	:	01/05/2007
Last Update Date	:	07/08/2007

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