MEDICARE: MR. ANTHONY DESANTO-KELLY LICENSE PYSCH TECH 3

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	167G00000X	Licensed Psychiatric Technician	PT24452	CA

General Provider Information

NPI Number	:	1417047069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANTHONY DESANTO-KELLY LICENSE PYSCH TECH 3

Provider Business Mailing Address
First Line	:	12857 FREDERICK ST APT 304
Second Line	:
City	:	MORENO VALLEY
State	:	CA
Zip	:	92553-4502
Country	:	US
Telephone Number	:	951-653-3141
Fax Number	:

Provider Business Practice Location Address
First Line	:	3501 N LAKEWOOD BLVD
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90808-1736
Country	:	US
Telephone Number	:	562-570-7119
Fax Number	:

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

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	07/08/2007

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