1215085527 NPI number — MRS. KELLY DANIELE MCDADE-MENDUS MFT

Table of content: MRS. KELLY DANIELE MCDADE-MENDUS MFT (NPI 1215085527)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215085527 NPI number — MRS. KELLY DANIELE MCDADE-MENDUS MFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCDADE-MENDUS
Provider First Name:
KELLY
Provider Middle Name:
DANIELE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MFT
Provider Gender Code:
F

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:
1215085527
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7803 TOMMY DR APT 66
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92119-1795
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-698-4210
Provider Business Mailing Address Fax Number:
619-258-0676

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4926 LA CUENTA DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92124-2609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-303-2265
Provider Business Practice Location Address Fax Number:
619-258-0676
Provider Enumeration Date:
01/05/2007

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:  MFC42198 , 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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