Basic Information
| Provider Information | |||||||||
| NPI: | 1790136364 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRIDAY | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | DANIELLE | ||||||||
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| Credential: | CATC; 112519 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1729 S MEYLER ST | ||||||||
| Address2: | APT 1 | ||||||||
| City: | SAN PEDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907314649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108319411 | ||||||||
| FaxNumber: | 3105219241 | ||||||||
| Practice Location | |||||||||
| Address1: | 235 W 9TH ST | ||||||||
| Address2: | |||||||||
| City: | SAN PEDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907313711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105219209 | ||||||||
| FaxNumber: | 3105219241 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2016 | ||||||||
| LastUpdateDate: | 06/24/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CATC 112519 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.