Provider Demographics
NPI:1174818728
Name:MERSEREAU, KATHLEEN MARIE (MFT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:MERSEREAU
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 BAYPOINT DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-8420
Mailing Address - Country:US
Mailing Address - Phone:415-717-5521
Mailing Address - Fax:
Practice Address - Street 1:1330 LINCOLN AVE STE 201
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2142
Practice Address - Country:US
Practice Address - Phone:415-459-5999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-12
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program