Provider Demographics
NPI:1710270525
Name:TKAC, KATHRYN (SUDCC)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:
Last Name:TKAC
Suffix:
Gender:F
Credentials:SUDCC
Other - Prefix:MS
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:TKAC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SUDCC
Mailing Address - Street 1:3545 E ASHLAN AVE
Mailing Address - Street 2:APT#152
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-3538
Mailing Address - Country:US
Mailing Address - Phone:559-226-5612
Mailing Address - Fax:
Practice Address - Street 1:2772 SOUTH MARTIN LUTHER KING JR. BLVD.
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706
Practice Address - Country:US
Practice Address - Phone:559-265-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-26
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6973101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6973OtherSUDCC