Basic Information
| Provider Information | |||||||||
| NPI: | 1891029005 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MINER-GANN | ||||||||
| FirstName: | KELLY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 844 OLD TUNNEL RD | ||||||||
| Address2: | |||||||||
| City: | GRASS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959458524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302734984 | ||||||||
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| Practice Location | |||||||||
| Address1: | 844 OLD TUNNEL RD | ||||||||
| Address2: | |||||||||
| City: | GRASS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959458524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302734984 | ||||||||
| FaxNumber: | 5302734573 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2009 | ||||||||
| LastUpdateDate: | 03/13/2018 | ||||||||
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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 | 101YM0800X | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | FHC 70042F | 01 | CA | SANTA CRUZ COUNTY MEDI-CAL PROVIDER # | OTHER | FHC 70044F | 01 | CA | SANTA CRUZ COUNTY MEDI-CAL PROVIDER # | OTHER | ZZZ91891Z | 01 | CA | SANTA CRUZ COUNTY MEDICARE GROUP PTAN# | OTHER | ZZZ91892Z | 01 | CA | SANTA CRUZ COUNTY MEDICARE GROUP PTAN# | OTHER | ZZZ92069Z | 01 | CA | SANTA CRUZ COUNTY MEDICARE GROUP PTAN# | OTHER |