Provider Demographics
NPI:1467583419
Name:VAN STONE, KATHY MARIE (PSYD)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:MARIE
Last Name:VAN STONE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 SCOTT BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76504-6803
Mailing Address - Country:US
Mailing Address - Phone:512-201-4006
Mailing Address - Fax:
Practice Address - Street 1:5806 MESA DR STE 300
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3783
Practice Address - Country:US
Practice Address - Phone:512-201-4006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19357103T00000X, 103TH0100X
TX35086103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ06382Medicare UPIN
CAWCP19357AMedicare ID - Type UnspecifiedMEDICARE PROVIDER #
TXTXB133488Medicare PIN