Provider Demographics
NPI:1538287289
Name:SHAMP, KATHLEEN MARIE (MFT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:SHAMP
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 576013
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-6013
Mailing Address - Country:US
Mailing Address - Phone:209-541-7169
Mailing Address - Fax:
Practice Address - Street 1:1501 CLAUS RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-9711
Practice Address - Country:US
Practice Address - Phone:209-541-7169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47366106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist