Provider Demographics
NPI:1437963485
Name:KAELYN MARIE LICENSED PROFESSIONAL CLINICAL COUNSELOR INC
Entity type:Organization
Organization Name:KAELYN MARIE LICENSED PROFESSIONAL CLINICAL COUNSELOR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KAELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:509-951-2783
Mailing Address - Street 1:4583 MARYLAND ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-1158
Mailing Address - Country:US
Mailing Address - Phone:509-951-2783
Mailing Address - Fax:
Practice Address - Street 1:3033 FIFTH AVE STE 230
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5873
Practice Address - Country:US
Practice Address - Phone:323-628-8452
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-01
Last Update Date:2025-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)