Provider Demographics
NPI:1275357816
Name:MICHELLE KELLEY, LCSW
Entity type:Organization
Organization Name:MICHELLE KELLEY, LCSW
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:360-449-2505
Mailing Address - Street 1:30435 MOONLIGHT CT
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-7346
Mailing Address - Country:US
Mailing Address - Phone:360-449-2505
Mailing Address - Fax:
Practice Address - Street 1:41690 ENTERPRISE CIR N STE 230
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5660
Practice Address - Country:US
Practice Address - Phone:360-449-2505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-11
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)