Healthcare Provider Details

I. General information

NPI: 1700517695
Provider Name (Legal Business Name): KATHLEEN MICHELLE VAKOC AMFT APCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2022
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E OLIVE AVE STE 100
REDLANDS CA
92373-5255
US

IV. Provider business mailing address

12379 CAMBRIA DR
YUCAIPA CA
92399-1969
US

V. Phone/Fax

Practice location:
  • Phone: 909-409-5781
  • Fax:
Mailing address:
  • Phone: 909-855-9519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT149579
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberAPCC17678
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: