Basic Information
| Provider Information | |||||||||
| NPI: | 1609082726 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICHEAL | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3960 WALNUT DR | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955038938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072688722 | ||||||||
| FaxNumber: | 7072680218 | ||||||||
| Practice Location | |||||||||
| Address1: | 3960 WALNUT DR | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072688722 | ||||||||
| FaxNumber: | 7072680218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 08/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC23336 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | MFT233360 | 01 | CA | BLUE SHIELD | OTHER | 287020 | 01 | CA | MHN | OTHER | 544324000 | 01 | CA | MAGELLAN | OTHER | 700164 | 05 | CA | MEDICAID |