Provider Demographics
NPI:1609082726
Name:RICHEAL, KELLY ANN (MFT)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANN
Last Name:RICHEAL
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3960 WALNUT DR
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95503-8938
Mailing Address - Country:US
Mailing Address - Phone:707-268-8722
Mailing Address - Fax:707-268-0218
Practice Address - Street 1:3960 WALNUT DR
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95503
Practice Address - Country:US
Practice Address - Phone:707-268-8722
Practice Address - Fax:707-268-0218
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC23336106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFT233360OtherBLUE SHIELD
CA287020OtherMHN
CA544324000OtherMAGELLAN
CA700164Medicaid
CAMFT233360OtherBLUE SHIELD