Provider Demographics
NPI:1417020561
Name:FENTRESS, KATHRYN J (PHD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:J
Last Name:FENTRESS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5007 SAMISH WAY
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98229-8917
Mailing Address - Country:US
Mailing Address - Phone:360-738-6884
Mailing Address - Fax:360-738-6884
Practice Address - Street 1:5007 SAMISH WAY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98229-8917
Practice Address - Country:US
Practice Address - Phone:360-738-6884
Practice Address - Fax:360-738-6884
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY0003642103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8466286Medicaid
WA1009812Medicaid
WAG8912346Medicare UPIN