Provider Demographics
NPI:1326286295
Name:RATHMANN, KELLY ALEXIS (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ALEXIS
Last Name:RATHMANN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-3202
Mailing Address - Country:US
Mailing Address - Phone:707-695-6427
Mailing Address - Fax:
Practice Address - Street 1:3650 STANDISH AVENUE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407
Practice Address - Country:US
Practice Address - Phone:707-695-6427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-29
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW287961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical