Healthcare Provider Details

I. General information

NPI: 1235276080
Provider Name (Legal Business Name): KATHERINE ANN KIRK MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 10/11/2026
Certification Date: 10/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 TWIN LAKES DR
SANTA ROSA CA
95409-6444
US

IV. Provider business mailing address

PO BOX 114
KENWOOD CA
95452-0114
US

V. Phone/Fax

Practice location:
  • Phone: 369-210-8063
  • Fax: 808-465-3261
Mailing address:
  • Phone: 369-210-8063
  • Fax: 808-465-3261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC297
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC46475
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: