Healthcare Provider Details

I. General information

NPI: 1568304996
Provider Name (Legal Business Name): KATHLEEN BOMIE PAE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2368 MARITIME DR
ELK GROVE CA
95758-3652
US

IV. Provider business mailing address

1130 BELL ST UNIT 1
SACRAMENTO CA
95825-3594
US

V. Phone/Fax

Practice location:
  • Phone: 916-580-1100
  • Fax:
Mailing address:
  • Phone: 213-255-8972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: