Provider Demographics
NPI:1710546940
Name:DETTMER, KATHERINE M (LSW)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:M
Last Name:DETTMER
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:SCHULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:1061 A ST
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-4105
Mailing Address - Country:US
Mailing Address - Phone:510-270-1150
Mailing Address - Fax:
Practice Address - Street 1:1061 A ST
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-4105
Practice Address - Country:US
Practice Address - Phone:510-270-1150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06130700104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker