Healthcare Provider Details

I. General information

NPI: 1306367032
Provider Name (Legal Business Name): KATHALEEN R REAGAN LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8950 VILLA LA JOLLA DR STE C230
LA JOLLA CA
92037-1712
US

IV. Provider business mailing address

8950 VILLA LA JOLLA DR STE C230
LA JOLLA CA
92037-1712
US

V. Phone/Fax

Practice location:
  • Phone: 925-282-1778
  • Fax: 415-296-5299
Mailing address:
  • Phone: 925-282-1778
  • Fax: 415-296-5299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4032
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPCC7527
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: