Active NPI
Mary Pat Kelly, PH.D.
- Clinical Psychologist
- Laguna Beach, CA
National Provider Identifier
1235348509
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- PSY12662
- Practice address
- 380 Glenneyre St Ste D
Laguna Beach, CA 92651-2303 - Phone
- (949) 494-0093
- Fax
- (949) 497-0913
- NPI assigned
- May 22, 2007
- Last updated
- Jul 8, 2007
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | PSY12662 | CA | Primary |
Addresses
Primary practice location
380 Glenneyre St Ste D
Laguna Beach, CA 92651-2303
Mailing address
380 Glenneyre St Ste D
Laguna Beach, CA 92651-2303
Phone (949) 494-0093
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Jan 1, 2021 through Jan 1, 2027
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PSY12662 | CA | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1179792000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1235348509",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "380 GLENNEYRE ST STE D",
"city": "LAGUNA BEACH",
"state": "CA",
"postal_code": "926512303",
"telephone_number": "949-494-0093",
"fax_number": "949-497-0913"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "380 GLENNEYRE ST STE D",
"city": "LAGUNA BEACH",
"state": "CA",
"postal_code": "926512303",
"telephone_number": "949-494-0093",
"fax_number": "949-497-0913"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KELLY",
"first_name": "MARY",
"middle_name": "PAT",
"name_prefix": "Dr.",
"credential": "PH.D.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2007-05-22",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "CA",
"license": "PSY12662",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Laguna Beach, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.