Provider Demographics
NPI:1417782608
Name:CUBILLOS, KELLI (AMFT)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:CUBILLOS
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1132
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-0132
Mailing Address - Country:US
Mailing Address - Phone:657-213-1988
Mailing Address - Fax:
Practice Address - Street 1:1910 OLYMPIC BLVD STE 210A
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-5096
Practice Address - Country:US
Practice Address - Phone:877-676-7634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT130808106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist