Provider Demographics
NPI:1437661402
Name:PACHECO- GAGNER, KELLY SUE (MS, LPCC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:SUE
Last Name:PACHECO- GAGNER
Suffix:
Gender:
Credentials:MS, LPCC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:PACHECO-GAGNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, LPCC
Mailing Address - Street 1:6200 WILSHIRE BLVD STE 1410
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5815
Mailing Address - Country:US
Mailing Address - Phone:925-282-1778
Mailing Address - Fax:
Practice Address - Street 1:6200 WILSHIRE BLVD STE 1410
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5815
Practice Address - Country:US
Practice Address - Phone:925-282-1778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA17859101YM0800X, 101YP2500X
ORC9686101YP2500X
CALPCC17859101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health