Provider Demographics
NPI:1528600491
Name:WHITESIDE, KATRINA
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:WHITESIDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4419 CORNFIELD WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-6043
Mailing Address - Country:US
Mailing Address - Phone:916-428-2398
Mailing Address - Fax:
Practice Address - Street 1:4250 AUBURN BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95841-4100
Practice Address - Country:US
Practice Address - Phone:888-965-6647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 390200000X
CA1024471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program