Basic Information
| Provider Information | |||||||||
| NPI: | 1194870949 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIN | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | BRYAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2711 ALCATRAZ AVE STE 2 | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947052726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102197091 | ||||||||
| FaxNumber: | 5102699031 | ||||||||
| Practice Location | |||||||||
| Address1: | 2711 ALCATRAZ AVE STE 2 | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947052726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102197091 | ||||||||
| FaxNumber: | 5102699031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC 38529 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 103T00000X | 20624 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | PSY 20624 | CA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.