Provider Demographics
NPI:1639635691
Name:STAN, KATHY A (MA, LPC, NCC)
Entity Type:Individual
Prefix:MS
First Name:KATHY
Middle Name:A
Last Name:STAN
Suffix:
Gender:F
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 DAWN DR STE 108
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-2800
Mailing Address - Country:US
Mailing Address - Phone:512-426-9488
Mailing Address - Fax:
Practice Address - Street 1:3003 DAWN DR STE 108
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-2800
Practice Address - Country:US
Practice Address - Phone:512-426-9488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX77521101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX77521OtherLPC LICENSE