MEDICARE: KELSEY JUNE HERMANN APCC, PPS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	101YS0200X	School Counselor		CA
3	101YP2500X	Professional Counselor	11519	CA
4	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility

General Provider Information

NPI Number	:	1720733272
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSEY JUNE HERMANN APCC, PPS

Provider Business Mailing Address
First Line	:	4004 GLOSTER WAY
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95834-2038
Country	:	US
Telephone Number	:	916-928-5316
Fax Number	:

Provider Business Practice Location Address
First Line	:	4004 GLOSTER WAY
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95834-2038
Country	:	US
Telephone Number	:	916-928-5316
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2022
Last Update Date	:	12/11/2025

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