Healthcare Provider Details

I. General information

NPI: 1831013739
Provider Name (Legal Business Name): KATHRYN ANN MACKILLOP LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 W 3RD ST
SANTA ROSA CA
95401-6409
US

IV. Provider business mailing address

2408 BAGGETT DR
SANTA ROSA CA
95401-5785
US

V. Phone/Fax

Practice location:
  • Phone: 707-979-6885
  • Fax:
Mailing address:
  • Phone: 707-508-8795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number113075
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: