Healthcare Provider Details

I. General information

NPI: 1508686536
Provider Name (Legal Business Name): KATHERINE T T KOOYMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 10/15/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CADILLAC DR APT 94
SACRAMENTO CA
95825-5465
US

IV. Provider business mailing address

100 CADILLAC DR APT 94
SACRAMENTO CA
95825-5465
US

V. Phone/Fax

Practice location:
  • Phone: 510-439-8253
  • Fax:
Mailing address:
  • Phone: 510-439-8253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLEP3995
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT103202
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: