Provider Demographics
NPI:1982442596
Name:MKRTYCHAN, YELENA
Entity type:Individual
Prefix:
First Name:YELENA
Middle Name:
Last Name:MKRTYCHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-4404
Mailing Address - Country:US
Mailing Address - Phone:916-749-4646
Mailing Address - Fax:
Practice Address - Street 1:10200 COUNTRY WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95827-2414
Practice Address - Country:US
Practice Address - Phone:916-524-5476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY3300083106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician