Provider Demographics
NPI:1457490047
Name:CITRENBAUM, KATHLEEN (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:CITRENBAUM
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:PO BOX 521
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93515-0521
Mailing Address - Country:US
Mailing Address - Phone:760-872-4315
Mailing Address - Fax:
Practice Address - Street 1:308 W LINE ST
Practice Address - Street 2:SUITE #4
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-3438
Practice Address - Country:US
Practice Address - Phone:760-872-4315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 15475101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ00853ZMedicare ID - Type Unspecified