Healthcare Provider Details

I. General information

NPI: 1679902811
Provider Name (Legal Business Name): KATHLEEN MARIE ANDERSON MFC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2013
Last Update Date: 11/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 SHILOH RD BLDG 44, STE. G
WINDSOR CA
95492-9659
US

IV. Provider business mailing address

930 SHILOH RD BLDG 44, STE. G
WINDSOR CA
95492-9659
US

V. Phone/Fax

Practice location:
  • Phone: 707-477-9769
  • Fax: 707-836-1997
Mailing address:
  • Phone: 707-477-9769
  • Fax: 707-836-1997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number49419
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: