Provider Demographics
NPI:1154820389
Name:DUTKA, KELLY MARIE (LMFT, LPCC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:DUTKA
Suffix:
Gender:F
Credentials:LMFT, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 7TH STREET SUITE 306
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401
Mailing Address - Country:US
Mailing Address - Phone:310-446-7003
Mailing Address - Fax:
Practice Address - Street 1:1460 7TH STREET
Practice Address - Street 2:SUITE 306
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401
Practice Address - Country:US
Practice Address - Phone:310-446-7003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33493106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist