Basic Information
| Provider Information | |||||||||
| NPI: | 1306065032 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICHAEL | ||||||||
| FirstName: | KELLSIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | ASW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5005 TEXAS ST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921083721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196920727 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3705 MISSION BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921097104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195152444 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 1041C0700X | 24208 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.