Provider Demographics
NPI:1144960543
Name:MCKIBBEN, KELLY LYNN (RADT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:MCKIBBEN
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5392 SIERRA ROJA RD
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92603-3828
Mailing Address - Country:US
Mailing Address - Phone:949-350-5202
Mailing Address - Fax:
Practice Address - Street 1:20331 FLANAGAN ROAD
Practice Address - Street 2:
Practice Address - City:TRABUCO CANYON
Practice Address - State:CA
Practice Address - Zip Code:92679
Practice Address - Country:US
Practice Address - Phone:818-582-8832
Practice Address - Fax:818-582-8836
Is Sole Proprietor?:No
Enumeration Date:2022-04-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1439310721101YA0400X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)