MEDICARE: MRS. KELLY MARIE VALLEJO LGSW

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	1041C0700X	Clinical Social Worker	17116	MD

General Provider Information

NPI Number	:	1548695653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY MARIE VALLEJO LGSW

Provider Business Mailing Address
First Line	:	CMR 490 BOX 2418
Second Line	:
City	:	APO
State	:	AE
Zip	:	09708-0025
Country	:	US
Telephone Number	:	48-657-0710
Fax Number	:

Provider Business Practice Location Address
First Line	:	CMR 402 BOX 4
Second Line	:
City	:	APO
State	:	AE
Zip	:	09180-0001
Country	:	US
Telephone Number	:	496371865886
Fax Number	:

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

Provider Enumeration Date	:	09/09/2013
Last Update Date	:	09/09/2013

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