MEDICARE: KATHRYN BLACKTHORN MSW, LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCSW76317	CA

General Provider Information

NPI Number	:	1922492347
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHRYN BLACKTHORN MSW, LCSW

Provider Business Mailing Address
First Line	:	PO BOX 1362
Second Line	:
City	:	EL DORADO
State	:	CA
Zip	:	95623-1362
Country	:	US
Telephone Number	:	916-879-5011
Fax Number	:

Provider Business Practice Location Address
First Line	:	7404 MICA ST
Second Line	:
City	:	EL DORADO
State	:	CA
Zip	:	95623-4849
Country	:	US
Telephone Number	:	916-879-5011
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2015
Last Update Date	:	07/19/2022

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