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NPI Code Detail

MEDICARE: MS. ANGEL RENE KELLY-BLAYDES MSW

MEDICARE: MS. ANGEL RENE KELLY-BLAYDES MSW
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
11041C0700XClinical Social WorkerLCS11623CA

General Provider Information

NPI Number : 1235201385
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. ANGEL RENE KELLY-BLAYDES MSW
Provider Business Mailing Address
First Line : 1500 S MCDONNELL AVE
Second Line :
City : LOS ANGELES
State : CA
Zip : 90040-5623
Country : US
Telephone Number : 323-981-4308
Fax Number : 323-269-2541
Provider Business Practice Location Address
First Line : 1500 S MCDONNELL AVE
Second Line :
City : LOS ANGELES
State : CA
Zip : 90040-5623
Country : US
Telephone Number : 323-981-4308
Fax Number : 323-269-2541
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/14/2006
Last Update Date : 03/11/2008

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