Provider Demographics
NPI:1134004476
Name:KELLY-KILGORE, CAITLYN MARIE (MS)
Entity type:Individual
Prefix:
First Name:CAITLYN
Middle Name:MARIE
Last Name:KELLY-KILGORE
Suffix:
Gender:X
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1585 62ND ST UNIT 8643
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94662-7027
Mailing Address - Country:US
Mailing Address - Phone:510-560-6056
Mailing Address - Fax:
Practice Address - Street 1:936 DEWING AVE STE G
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-4277
Practice Address - Country:US
Practice Address - Phone:925-322-1747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-06
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA156885106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist