Provider Demographics
NPI:1083041651
Name:CACCIATORE, CAROLYN ANN (MA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ANN
Last Name:CACCIATORE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 KUCK LN
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-9606
Mailing Address - Country:US
Mailing Address - Phone:707-795-6954
Mailing Address - Fax:
Practice Address - Street 1:365 KUCK LN
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-9606
Practice Address - Country:US
Practice Address - Phone:707-795-6954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-27
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 76011101YM0800X, 101Y00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor