Provider Demographics
NPI:1548695653
Name:VALLEJO, KELLY MARIE (LGSW)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIE
Last Name:VALLEJO
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LGSW
Mailing Address - Street 1:CMR 490 BOX 2418
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09708-0025
Mailing Address - Country:US
Mailing Address - Phone:048-657-0710
Mailing Address - Fax:
Practice Address - Street 1:CMR 402 BOX 4
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180-0001
Practice Address - Country:US
Practice Address - Phone:49637-186-5886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD171161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical