Provider Demographics
NPI:1306243530
Name:FUJIMOTO, KELL
Entity type:Individual
Prefix:
First Name:KELL
Middle Name:
Last Name:FUJIMOTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 MOORPARK AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-3158
Mailing Address - Country:US
Mailing Address - Phone:408-622-9302
Mailing Address - Fax:
Practice Address - Street 1:2845 MOORPARK AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-3158
Practice Address - Country:US
Practice Address - Phone:408-622-9302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19682103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical