Individual
KEVIN THOMAS KELLY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PH.D.
Contact information
Practice address
598 COCHRANE AVE, UKIAH, CA 95482-5621
(707) 463-1447
(866) 204-9690
Mailing address
598 COCHRANE AVE, UKIAH, CA 95482-5621
(707) 463-1447
(866) 204-9690
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
PSY9275
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
#00PL92750
BLUE SHIELD SUBMITTER
CA
01
—
7809105
BLUE CROSS PIN
CA
01
—
A00PL92750
BLUE SHIELD UIC #
CA
01
—
PA0092759
MEDI-CAL
CA
01
—
PSY00009275
BLUE CROSS
CA
Enumeration date
08/20/2007
Last updated
08/20/2007
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