Provider Demographics
NPI:1093842197
Name:PAXTON, KATHLEEN MARIE (CADC II A8378702)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:PAXTON
Suffix:
Gender:F
Credentials:CADC II A8378702
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 E MORRIS AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0437
Mailing Address - Country:US
Mailing Address - Phone:209-573-1691
Mailing Address - Fax:209-567-4112
Practice Address - Street 1:421 E MORRIS AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-0437
Practice Address - Country:US
Practice Address - Phone:209-573-1691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACADC II A8378702101YA0400X
CA65132106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)