Provider Demographics
NPI:1578719134
Name:REISIG, KATHRYN C (MFT)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:C
Last Name:REISIG
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:C
Other - Last Name:PETERON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1616 SIR FRANCIS DRAKE BLVD APT D
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-1872
Mailing Address - Country:US
Mailing Address - Phone:415-342-0882
Mailing Address - Fax:
Practice Address - Street 1:9860 MIDDLE CREEK RD
Practice Address - Street 2:
Practice Address - City:UPPER LAKE
Practice Address - State:CA
Practice Address - Zip Code:95485-9265
Practice Address - Country:US
Practice Address - Phone:707-275-8166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-14
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 41169106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist