Provider Demographics
NPI:1285975672
Name:WELLINGTON, KEISHA SUE-ANN
Entity type:Individual
Prefix:MS
First Name:KEISHA
Middle Name:SUE-ANN
Last Name:WELLINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KEISHA
Other - Middle Name:S
Other - Last Name:GALLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15135 KIMBERLY DR
Mailing Address - Street 2:APARTMENT O-104
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92394-7025
Mailing Address - Country:US
Mailing Address - Phone:442-242-2279
Mailing Address - Fax:
Practice Address - Street 1:13901 AMARGOSA RD
Practice Address - Street 2:SUITE 2
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2409
Practice Address - Country:US
Practice Address - Phone:760-512-1925
Practice Address - Fax:626-737-1095
Is Sole Proprietor?:No
Enumeration Date:2013-03-08
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst