Provider Demographics
NPI:1982446217
Name:TREFON, KELLY LOIS
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LOIS
Last Name:TREFON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 S WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-9107
Mailing Address - Country:US
Mailing Address - Phone:907-782-8377
Mailing Address - Fax:907-283-0084
Practice Address - Street 1:508 UPLAND ST
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-8026
Practice Address - Country:US
Practice Address - Phone:907-335-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-07
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1753397Medicaid