Basic Information
| Provider Information | |||||||||
| NPI: | 1093360331 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLAR | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | DIANE | ||||||||
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| Credential: | RADT | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 717 LINCOLN BLVD | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902912845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103999883 | ||||||||
| FaxNumber: | 3103999678 | ||||||||
| Practice Location | |||||||||
| Address1: | 717 LINCOLN BLVD | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902912845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103999883 | ||||||||
| FaxNumber: | 3103999678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2019 | ||||||||
| LastUpdateDate: | 08/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | R8617 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.