Provider Demographics
NPI:1225470503
Name:PEMBERTON, KELLY (LMFT #100286)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PEMBERTON
Suffix:
Gender:F
Credentials:LMFT #100286
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19002
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-0002
Mailing Address - Country:US
Mailing Address - Phone:916-668-0297
Mailing Address - Fax:
Practice Address - Street 1:2701 I ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-4309
Practice Address - Country:US
Practice Address - Phone:916-668-0297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA2765103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool