Provider Demographics
NPI:1225349145
Name:KERIDAN, KATIE JO (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KATIE
Middle Name:JO
Last Name:KERIDAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 HURLBUT AVE
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-2881
Mailing Address - Country:US
Mailing Address - Phone:707-835-4252
Mailing Address - Fax:
Practice Address - Street 1:825 COLLEGE AVE STE 4
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4108
Practice Address - Country:US
Practice Address - Phone:510-428-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-24
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY29632103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist