Provider Demographics
NPI:1407910656
Name:STUTZ, KATHLEEN GRACE (MFT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:GRACE
Last Name:STUTZ
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:PO BOX 422
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:CA
Mailing Address - Zip Code:95625-0422
Mailing Address - Country:US
Mailing Address - Phone:707-548-4332
Mailing Address - Fax:
Practice Address - Street 1:1300 OLIVER RD
Practice Address - Street 2:SUITE 193
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-3413
Practice Address - Country:US
Practice Address - Phone:707-548-4332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 46746106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4438OtherMENTAL HEALTH
CA1454OtherNNA