Provider Demographics
NPI:1114325818
Name:KEITHLY, KATHRYN MURPHY (PPS, LEP, MA)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MURPHY
Last Name:KEITHLY
Suffix:
Gender:F
Credentials:PPS, LEP, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 293
Mailing Address - Street 2:
Mailing Address - City:AROMAS
Mailing Address - State:CA
Mailing Address - Zip Code:95004-0293
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5324 HIDDEN OAK COURT
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95004-0293
Practice Address - Country:US
Practice Address - Phone:831-234-4182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-11
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 103TC1900X, 103TE1100X, 103TS0200X
CALEP3485103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool