Provider Demographics
NPI:1174907117
Name:MIYAKAWA, KELLY FIERRO (LCSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:FIERRO
Last Name:MIYAKAWA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28039 SCOTT ROAD
Mailing Address - Street 2:STE D #283
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-1181
Mailing Address - Country:US
Mailing Address - Phone:909-720-3591
Mailing Address - Fax:
Practice Address - Street 1:30877 BLOOMFEST ST
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563
Practice Address - Country:US
Practice Address - Phone:909-720-3591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-18
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA880991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)