Provider Demographics
NPI:1093190498
Name:KELLY, VIVIAN FIGUEROA
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:FIGUEROA
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1484 POLLARD RD # 3049
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-1031
Mailing Address - Country:US
Mailing Address - Phone:408-426-9525
Mailing Address - Fax:
Practice Address - Street 1:1484 POLLARD RD # 3049
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-1031
Practice Address - Country:US
Practice Address - Phone:408-426-9525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-27
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 101YM0800X, 390200000X
CALCSW92879101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program