MEDICARE: ANGELINE KELLY LMFT

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	162246	CA

General Provider Information

NPI Number	:	1821745498
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELINE KELLY LMFT

Provider Business Mailing Address
First Line	:	1006 PHILLIPS AVE
Second Line	:
City	:	PETALUMA
State	:	CA
Zip	:	94952-4829
Country	:	US
Telephone Number	:	707-494-7311
Fax Number	:

Provider Business Practice Location Address
First Line	:	133 1/2 KENTUCKY ST STE B
Second Line	:
City	:	PETALUMA
State	:	CA
Zip	:	94952-2925
Country	:	US
Telephone Number	:	707-242-4077
Fax Number	:

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

Provider Enumeration Date	:	03/03/2022
Last Update Date	:	06/10/2026

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Directions to “ ANGELINE KELLY LMFT” Practice Location

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