Provider Demographics
NPI:1902287543
Name:SHELBY, KELLY
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:SHELBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 26TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601
Mailing Address - Country:US
Mailing Address - Phone:510-496-5140
Mailing Address - Fax:510-496-5146
Practice Address - Street 1:16929 HARVARD AVE
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-1350
Practice Address - Country:US
Practice Address - Phone:510-496-5140
Practice Address - Fax:510-496-5146
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-09
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAP0810281124101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional