Healthcare Provider Details

I. General information

NPI: 1366916785
Provider Name (Legal Business Name): KATIE COLUNGA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2019
Last Update Date: 05/28/2022
Certification Date: 05/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

867 N FAIR OAKS AVE
PASADENA CA
91103-3050
US

IV. Provider business mailing address

1630 S BARRANCA AVE SPC 31
GLENDORA CA
91740-5419
US

V. Phone/Fax

Practice location:
  • Phone: 626-798-6793
  • Fax:
Mailing address:
  • Phone: 661-319-8673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number109241
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number130455
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: