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General NPI Number Information
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NPI Number | 1225349145
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Entity Type | Individual
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Provider Name | KATIE JO KERIDAN PSY.D.
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Gender | Female
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Dates
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Enumeration Date | 06/24/2010
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Last Update Date | 09/26/2018
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Provider Practice Location Address
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Address Line | 825 COLLEGE AVE STE 4
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City | SANTA ROSA
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State | CA
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Zip | 95404-4108
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Country | US
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Telephone | 510-428-3000
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Fax |
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Provider Business Mailing Address
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Address Line | 1716 HURLBUT AVE
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City | SEBASTOPOL
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State | CA
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Zip | 95472-2881
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Country | US
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Telephone | 707-835-4252
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | PSY29632
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License Number State | CA
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