Provider Demographics
NPI:1124787767
Name:KELLIS, ZACHARY MICHAEL
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:MICHAEL
Last Name:KELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 WINCHESTER CT
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-4338
Mailing Address - Country:US
Mailing Address - Phone:707-470-9139
Mailing Address - Fax:
Practice Address - Street 1:354 CERNON ST
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-4502
Practice Address - Country:US
Practice Address - Phone:707-470-9139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician