MEDICARE: KELLIE MACK ANDERSON MFT

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	LMFT 4401	ID
2	106H00000X	Marriage & Family Therapist	MFC 47389	CA

General Provider Information

NPI Number	:	1972637445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLIE MACK ANDERSON MFT

Provider Business Mailing Address
First Line	:	2275 ARLINGTON DR
Second Line	:
City	:	SAN LEANDRO
State	:	CA
Zip	:	94578-1132
Country	:	US
Telephone Number	:	714-881-8638
Fax Number	:

Provider Business Practice Location Address
First Line	:	18302 IRVINE BLVD
Second Line	:	STE. 300
City	:	TUSTIN
State	:	CA
Zip	:	92780-3435
Country	:	US
Telephone Number	:	714-881-8638
Fax Number	:

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

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	11/08/2013

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