MEDICARE: DR. KELLY WARREN PSYD

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	103T00000X	Psychologist	PSY27851	CA

General Provider Information

NPI Number	:	1891105193
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY WARREN PSYD

Provider Business Mailing Address
First Line	:	2447 PACIFIC COAST HWY STE 213
Second Line	:
City	:	HERMOSA BEACH
State	:	CA
Zip	:	90254-2714
Country	:	US
Telephone Number	:	310-947-9279
Fax Number	:

Provider Business Practice Location Address
First Line	:	2447 PACIFIC COAST HWY STE 213
Second Line	:
City	:	HERMOSA BEACH
State	:	CA
Zip	:	90254-2714
Country	:	US
Telephone Number	:	310-947-9279
Fax Number	:

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

Provider Enumeration Date	:	05/07/2014
Last Update Date	:	05/10/2018

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