Provider Demographics
NPI:1215085527
Name:MCDADE-MENDUS, KELLY DANIELE (MFT)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:DANIELE
Last Name:MCDADE-MENDUS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7803 TOMMY DR APT 66
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-1795
Mailing Address - Country:US
Mailing Address - Phone:619-698-4210
Mailing Address - Fax:619-258-0676
Practice Address - Street 1:4926 LA CUENTA DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92124-2609
Practice Address - Country:US
Practice Address - Phone:619-303-2265
Practice Address - Fax:619-258-0676
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC42198106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist