Provider Demographics
NPI:1205422284
Name:CLOHESSY, KELLY (LAC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CLOHESSY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 LUCAS VALLEY RD # 317
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1791
Mailing Address - Country:US
Mailing Address - Phone:650-222-4066
Mailing Address - Fax:
Practice Address - Street 1:101 LUCAS VALLEY RD # 317
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-1791
Practice Address - Country:US
Practice Address - Phone:650-222-4066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA158883171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty