| Doctor Name: | MR. MIKE SEAN KELLY |
| NPI Number: | 1003206004 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | NP |
| License Number: | 95001913 |
| Business Practice Address: | 275 Victoria St Costa Mesa, CA - 926271906 |
| Business Phone Number: | 9497227118 |
| Business Fax Number: | 9497227118 |
| Mailing Address: | 215 Santa Isabel Ave, COSTA MESA |
| State: | CA |
| Postal Code: | 926271509 |
| Phone Number: | 9497227118 |
| Fax Number: | 9497227119 |
| NPI Enumeration Date: | 01/28/2015 |
| NPI Last Update Date: | 01/28/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LP0808X |
| License Number: | 95001913 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Psych/Mental Health |
| Taxonomy Definition: | |