Provider Demographics
NPI:1386348860
Name:EDGELL, KLEO CHELESE
Entity type:Individual
Prefix:
First Name:KLEO
Middle Name:CHELESE
Last Name:EDGELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 BEACON BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-3467
Mailing Address - Country:US
Mailing Address - Phone:916-462-3100
Mailing Address - Fax:
Practice Address - Street 1:801 EMPIRE ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-5702
Practice Address - Country:US
Practice Address - Phone:707-425-5744
Practice Address - Fax:707-425-5162
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes172V00000XOther Service ProvidersCommunity Health Worker