Provider Demographics
NPI:1255704086
Name:ORMOSEN, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ORMOSEN
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 231
Mailing Address - Street 2:
Mailing Address - City:PENRYN
Mailing Address - State:CA
Mailing Address - Zip Code:95663-0231
Mailing Address - Country:US
Mailing Address - Phone:530-218-6366
Mailing Address - Fax:
Practice Address - Street 1:1899 E ROSEVILLE PKWY STE 140
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-7980
Practice Address - Country:US
Practice Address - Phone:530-218-6366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-02
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88907106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist