Provider Demographics
NPI:1447308028
Name:PAQUETTE, KELLY MARIE (PSYD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:PAQUETTE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 ORIOLE CIR
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-6678
Mailing Address - Country:US
Mailing Address - Phone:415-794-2391
Mailing Address - Fax:
Practice Address - Street 1:100 MEADOWCREEK DR STE 115
Practice Address - Street 2:
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1230
Practice Address - Country:US
Practice Address - Phone:415-794-2391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY25608103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program