Provider Demographics
NPI:1053025858
Name:STAINER, KELLEEN CARRIE
Entity type:Individual
Prefix:
First Name:KELLEEN
Middle Name:CARRIE
Last Name:STAINER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 ANTON BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-7036
Mailing Address - Country:US
Mailing Address - Phone:949-204-0011
Mailing Address - Fax:
Practice Address - Street 1:555 ANTON BLVD STE 150
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-7036
Practice Address - Country:US
Practice Address - Phone:949-204-0011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW298341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical