Provider Demographics
NPI:1306065032
Name:MICHAEL, KELLSIE ANN (ASW)
Entity type:Individual
Prefix:
First Name:KELLSIE
Middle Name:ANN
Last Name:MICHAEL
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 1:5005 TEXAS ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3721
Mailing Address - Country:US
Mailing Address - Phone:619-692-0727
Mailing Address - Fax:
Practice Address - Street 1:3705 MISSION BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-7104
Practice Address - Country:US
Practice Address - Phone:619-515-2444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA242081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical