Provider Demographics
NPI:1194088807
Name:PHELPS, KELLEY LYNN
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:LYNN
Last Name:PHELPS
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 1:788 ALGIERS ST
Mailing Address - Street 2:
Mailing Address - City:MURPHYS
Mailing Address - State:CA
Mailing Address - Zip Code:95247-9583
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:788 ALGIERS ST
Practice Address - Street 2:
Practice Address - City:MURPHYS
Practice Address - State:CA
Practice Address - Zip Code:95247-9583
Practice Address - Country:US
Practice Address - Phone:415-758-0366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77190106H00000X
CALMFT98984106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist