Healthcare Provider Details

I. General information

NPI: 1730577917
Provider Name (Legal Business Name): KATHRYN DEBACA A.S., LCMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2014
Last Update Date: 04/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1424 MORRISON AVE
STOCKTON CA
95205-3538
US

IV. Provider business mailing address

PO BOX 1841
STOCKTON CA
95201-1841
US

V. Phone/Fax

Practice location:
  • Phone: 209-430-1461
  • Fax:
Mailing address:
  • Phone: 209-430-1461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number66723
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number66723
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License Number66723
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number60873
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: