Provider Demographics
NPI:1124263462
Name:HERRIN, KELLEY JOAN (M S, LMFT)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:JOAN
Last Name:HERRIN
Suffix:
Gender:F
Credentials:M S, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 S WASHINGTON ST
Mailing Address - Street 2:#1
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-4752
Mailing Address - Country:US
Mailing Address - Phone:209-743-9292
Mailing Address - Fax:209-532-6767
Practice Address - Street 1:6 S WASHINGTON ST
Practice Address - Street 2:#1
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-4752
Practice Address - Country:US
Practice Address - Phone:209-743-9292
Practice Address - Fax:209-532-6767
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-15
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 46046102L00000X
CAMFC46046106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst