Healthcare Provider Details

I. General information

NPI: 1811551104
Provider Name (Legal Business Name): KATHY EVELYN DI GIACOMO AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2019
Last Update Date: 04/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13975 MONO WAY STE G
SONORA CA
95370-2824
US

IV. Provider business mailing address

PO BOX 939
ANGELS CAMP CA
95222-0939
US

V. Phone/Fax

Practice location:
  • Phone: 209-533-9600
  • Fax:
Mailing address:
  • Phone: 209-754-6262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT108520
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: