Provider Demographics
NPI:1578366506
Name:LAM, KIELY
Entity type:Individual
Prefix:
First Name:KIELY
Middle Name:
Last Name:LAM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 REDWOOD WAY STE 210
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-1134
Mailing Address - Country:US
Mailing Address - Phone:217-246-7688
Mailing Address - Fax:
Practice Address - Street 1:1301 REDWOOD WAY STE 210
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-1134
Practice Address - Country:US
Practice Address - Phone:217-246-7688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-27
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician