Provider Demographics
NPI:1578609822
Name:PEDGRIFT, KATHRYN MARIE (PSYD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARIE
Last Name:PEDGRIFT
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 1:3780 FIFTH AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-4238
Mailing Address - Country:US
Mailing Address - Phone:415-710-4187
Mailing Address - Fax:
Practice Address - Street 1:10065 OLD GROVE RD STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-1664
Practice Address - Country:US
Practice Address - Phone:858-444-8823
Practice Address - Fax:858-444-8827
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA24991103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3740Medicaid