Provider Demographics
NPI:1881866168
Name:YEARGAN, KELLEY A (MFTI)
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:A
Last Name:YEARGAN
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:MS
Other - First Name:KELLEY
Other - Middle Name:A
Other - Last Name:BUSSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:3990 BRANCH CENTER RD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-3809
Mailing Address - Country:US
Mailing Address - Phone:916-596-4186
Mailing Address - Fax:
Practice Address - Street 1:700 H ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95814-1216
Practice Address - Country:US
Practice Address - Phone:916-875-4225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT77723106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist