Provider Demographics
NPI:1306367032
Name:REAGAN, KATHALEEN (PCCI)
Entity Type:Individual
Prefix:
First Name:KATHALEEN
Middle Name:
Last Name:REAGAN
Suffix:
Gender:F
Credentials:PCCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 E MOUNTAIN VIEW ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-2814
Mailing Address - Country:US
Mailing Address - Phone:760-256-7279
Mailing Address - Fax:
Practice Address - Street 1:309 E MOUNTAIN VIEW ST STE 100
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-2814
Practice Address - Country:US
Practice Address - Phone:760-256-7279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4032101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional