Provider Demographics
NPI:1073388385
Name:YERLY, ETHAN MICHAEL (RADT1)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:MICHAEL
Last Name:YERLY
Suffix:
Gender:M
Credentials:RADT1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 22ND ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-3503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 22ND ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-3503
Practice Address - Country:US
Practice Address - Phone:209-748-2470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-16
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1531801023101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)