Provider Demographics
NPI:1285908939
Name:VANAMBERG, KELLY S (ASW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:VANAMBERG
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1831 STANFORD ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-4117
Mailing Address - Country:US
Mailing Address - Phone:424-229-1509
Mailing Address - Fax:
Practice Address - Street 1:1831 STANFORD ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-4117
Practice Address - Country:US
Practice Address - Phone:424-229-1509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-28
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA749061041C0700X
CA92157101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical