Provider Demographics
NPI:1861771677
Name:KELLY, JUDY
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:
Last Name:KELLY
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:PO BOX 5422
Mailing Address - Street 2:
Mailing Address - City:NORCO
Mailing Address - State:CA
Mailing Address - Zip Code:92860-8014
Mailing Address - Country:US
Mailing Address - Phone:213-247-2100
Mailing Address - Fax:
Practice Address - Street 1:224 WEST GRAHAM AVE
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530
Practice Address - Country:US
Practice Address - Phone:951-318-1351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-10
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF73071106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist