Provider Demographics
NPI:1093003139
Name:MESEROLL, KATIE LEIGH (PSYD)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:LEIGH
Last Name:MESEROLL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:LEIGH
Other - Last Name:MESEROLL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 1420
Mailing Address - Street 2:
Mailing Address - City:SAUSALITO
Mailing Address - State:CA
Mailing Address - Zip Code:94966-1420
Mailing Address - Country:US
Mailing Address - Phone:707-484-7459
Mailing Address - Fax:
Practice Address - Street 1:1440 BROADWAY
Practice Address - Street 2:SUITE 610
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2041
Practice Address - Country:US
Practice Address - Phone:510-628-9065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program