Provider Demographics
NPI:1962607432
Name:KELLY, CHANNA ROOS
Entity type:Individual
Prefix:MRS
First Name:CHANNA
Middle Name:ROOS
Last Name:KELLY
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 1:7635 SAN VICENTE ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114-4734
Mailing Address - Country:US
Mailing Address - Phone:619-713-2328
Mailing Address - Fax:
Practice Address - Street 1:125 W MISSION AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-1720
Practice Address - Country:US
Practice Address - Phone:760-747-3424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist