Provider Demographics
NPI:1316096258
Name:HEWITT, KELLY
Entity type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:
Last Name:HEWITT
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 1:55 REED BLVD
Mailing Address - Street 2:APT 9
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-2341
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 MASON CIR
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-1203
Practice Address - Country:US
Practice Address - Phone:925-521-1270
Practice Address - Fax:925-521-1279
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5171OtherMEDICAL BILLING NUMBER