Provider Demographics
NPI:1528249091
Name:KELLY, CAROL ANN (EDD)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10451 TENNESSEE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-2329
Mailing Address - Country:US
Mailing Address - Phone:310-475-7434
Mailing Address - Fax:310-475-7844
Practice Address - Street 1:10451 TENNESSEE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-2329
Practice Address - Country:US
Practice Address - Phone:310-475-7434
Practice Address - Fax:310-475-7844
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-26
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 5359103T00000X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOPL53590OtherMEDICAL