Provider Demographics
NPI:1609376953
Name:EMIDY, KATHLEEN KELLY BARBOSA
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:KELLY BARBOSA
Last Name:EMIDY
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 1:1679 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-5212
Mailing Address - Country:US
Mailing Address - Phone:619-441-1907
Mailing Address - Fax:
Practice Address - Street 1:1679 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-5212
Practice Address - Country:US
Practice Address - Phone:619-441-1907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-13
Last Update Date:2019-03-01
Deactivation Date:2018-02-16
Deactivation Code:
Reactivation Date:2018-02-21
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator