Provider Demographics
NPI:1164817615
Name:DEHERRERA, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:DEHERRERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22287 MULHOLLAND HWY
Mailing Address - Street 2:#136
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-5157
Mailing Address - Country:US
Mailing Address - Phone:330-807-4509
Mailing Address - Fax:
Practice Address - Street 1:11027 S PIKES PEAK DR
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80138-7356
Practice Address - Country:US
Practice Address - Phone:330-807-4509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACD.0000138101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)