MEDICARE: DR. KATHLEEN DARK PH.D.

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	103TC0700X	Clinical Psychologist	PSY14725	CA

General Provider Information

NPI Number	:	1760868186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHLEEN DARK PH.D.

Provider Business Mailing Address
First Line	:	PO BOX 335
Second Line	:
City	:	HEALDSBURG
State	:	CA
Zip	:	95448-0335
Country	:	US
Telephone Number	:	707-583-2363
Fax Number	:	707-595-5385

Provider Business Practice Location Address
First Line	:	132 LELAND ST
Second Line	:	SUITE 3
City	:	SANTA ROSA
State	:	CA
Zip	:	95404-4030
Country	:	US
Telephone Number	:	707-583-2363
Fax Number	:	707-595-5385

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

Provider Enumeration Date	:	08/07/2015
Last Update Date	:	08/07/2015

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