Provider Demographics
NPI:1760576482
Name:YELLAM, KRISTIN HERDMAN (LCSW, MSW)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:HERDMAN
Last Name:YELLAM
Suffix:
Gender:F
Credentials:LCSW, MSW
Other - Prefix:MS
Other - First Name:KRISTIN
Other - Middle Name:RENE
Other - Last Name:HERDMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW, MSW
Mailing Address - Street 1:2085 RUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-2498
Mailing Address - Country:US
Mailing Address - Phone:951-955-7320
Mailing Address - Fax:
Practice Address - Street 1:2085 RUSTIN AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2498
Practice Address - Country:US
Practice Address - Phone:951-955-7320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 221781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical