Healthcare Provider Details

I. General information

NPI: 1316195449
Provider Name (Legal Business Name): KATRINA LYNNE SUPRISE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3322 CHANATE RD
SANTA ROSA CA
95404-1708
US

IV. Provider business mailing address

2225 CHALLENGER WAY
SANTA ROSA CA
95407-5772
US

V. Phone/Fax

Practice location:
  • Phone: 707-576-8181
  • Fax:
Mailing address:
  • Phone: 707-565-4970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number83565
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: