Provider Demographics
NPI:1306396767
Name:PREMO, KATHERINE ANN (LMFT)
Entity Type:Individual
Prefix:MISS
First Name:KATHERINE
Middle Name:ANN
Last Name:PREMO
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 W WASHINGTON AVE UNIT 212
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-3590
Mailing Address - Country:US
Mailing Address - Phone:715-379-6149
Mailing Address - Fax:
Practice Address - Street 1:6502 GRAND TETON PLZ STE 204
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1047
Practice Address - Country:US
Practice Address - Phone:608-338-1786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-10
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1149-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist