Provider Demographics
NPI:1124616792
Name:EZELL, KELLI ROSE (LCSW)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:ROSE
Last Name:EZELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8210 CONSTANTINE DR APT 25
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-1787
Mailing Address - Country:US
Mailing Address - Phone:714-401-1796
Mailing Address - Fax:
Practice Address - Street 1:8210 CONSTANTINE DR APT 25
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-1787
Practice Address - Country:US
Practice Address - Phone:714-401-1796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1194241041C0700X
CA96506104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker