MEDICARE: MRS. KAYLA ELIZABETH KELLY

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	102656	CA

General Provider Information

NPI Number	:	1316359060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KAYLA ELIZABETH KELLY

Provider Business Mailing Address
First Line	:	3255 WING ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-4638
Country	:	US
Telephone Number	:	619-840-9195
Fax Number	:

Provider Business Practice Location Address
First Line	:	1870 CORDELL CT STE 101
Second Line	:
City	:	EL CAJON
State	:	CA
Zip	:	92020-0915
Country	:	US
Telephone Number	:	619-448-9700
Fax Number	:	619-448-9711

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

Provider Enumeration Date	:	05/29/2014
Last Update Date	:	07/30/2019

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