Healthcare Provider Details

I. General information

NPI: 1316428683
Provider Name (Legal Business Name): KATHRYN FOUNTAIN STEELE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHRYN FOUNTAIN MOON PHD

II. Dates (important events)

Enumeration Date: 08/24/2018
Last Update Date: 08/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1733 ASTURIAS ST
ST AUGUSTINE FL
32080-5564
US

IV. Provider business mailing address

1733 ASTURIAS ST
ST AUGUSTINE FL
32080-5564
US

V. Phone/Fax

Practice location:
  • Phone: 678-233-7474
  • Fax:
Mailing address:
  • Phone: 678-233-7474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number10505943
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number385711
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number707946
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1284206
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1289
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: