MEDICARE: MARIA TERESA KELLEY LCSW

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	104100000X	Social Worker	LCS 22990	CA

General Provider Information

NPI Number	:	1649365438
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA TERESA KELLEY LCSW

Provider Business Mailing Address
First Line	:	3020 CHILDRENS WAY
Second Line	:	MC 5018
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-4223
Country	:	US
Telephone Number	:	858-966-5832
Fax Number	:

Provider Business Practice Location Address
First Line	:	3665 KEARNY VILLA RD
Second Line	:	SUITE 165
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-1953
Country	:	US
Telephone Number	:	858-966-5832
Fax Number	:	858-966-8470

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

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	03/18/2011

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