1568501682 NPI number — MR. KELLY M KILCOYNE LMFT

Table of content: MR. KELLY M KILCOYNE LMFT (NPI 1568501682)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568501682 NPI number — MR. KELLY M KILCOYNE LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KILCOYNE
Provider First Name:
KELLY
Provider Middle Name:
M
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LMFT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568501682
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1512
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN MATEO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-485-1512
Provider Business Mailing Address Fax Number:
650-342-5678

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 E 3RD AVE
Provider Second Line Business Practice Location Address:
SUITE 207-C
Provider Business Practice Location Address City Name:
SAN MATEO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94401-4051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-485-1512
Provider Business Practice Location Address Fax Number:
650-342-5678
Provider Enumeration Date:
02/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  LMFT51065 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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