Healthcare Provider Details

I. General information

NPI: 1558620419
Provider Name (Legal Business Name): KATHLEEN WONACOTT MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2012
Last Update Date: 04/27/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5297 COLLEGE AVE STE 103
OAKLAND CA
94618
US

IV. Provider business mailing address

4900 SHATTUCK AVE UNIT 3593
OAKLAND CA
94609-7022
US

V. Phone/Fax

Practice location:
  • Phone: 415-457-3755
  • Fax: 415-457-0849
Mailing address:
  • Phone: 415-457-3755
  • Fax: 415-457-0849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number77334
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: