Provider Demographics
NPI:1194870949
Name:GIN, KELLEY BRYAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:BRYAN
Last Name:GIN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 ALCATRAZ AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2726
Mailing Address - Country:US
Mailing Address - Phone:510-219-7091
Mailing Address - Fax:510-269-9031
Practice Address - Street 1:2711 ALCATRAZ AVE STE 2
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2726
Practice Address - Country:US
Practice Address - Phone:510-219-7091
Practice Address - Fax:510-269-9031
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 38529106H00000X
CA20624103T00000X
CAPSY 20624103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical