Provider Demographics
NPI:1104311588
Name:HUBERTY, KELSEY (MA, LAADC)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:HUBERTY
Suffix:
Gender:F
Credentials:MA, LAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19126 MAGNOLIA ST STE 101
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-2235
Mailing Address - Country:US
Mailing Address - Phone:714-377-7706
Mailing Address - Fax:714-377-7715
Practice Address - Street 1:19126 MAGNOLIA ST STE 101
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-2235
Practice Address - Country:US
Practice Address - Phone:714-377-7706
Practice Address - Fax:714-377-7715
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALR02660117101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)