=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891322483
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHERINE JANE ELDEAN MA, MFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2020
-----------------------------------------------------
Last Update Date | 01/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 351 SANTE FE DR. SUITE 200
-----------------------------------------------------
City | ENCINITAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-342-0585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 107 E 38TH ST
-----------------------------------------------------
City | HOLLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49423-7066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-342-0585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 49558
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------