Provider Demographics
NPI:1710964630
Name:PERRY, KITTI JEAN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KITTI
Middle Name:JEAN
Last Name:PERRY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3
Mailing Address - Street 2:
Mailing Address - City:BODEGA BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94923-0003
Mailing Address - Country:US
Mailing Address - Phone:707-527-0610
Mailing Address - Fax:707-875-8873
Practice Address - Street 1:3000 CLEVELAND AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2171
Practice Address - Country:US
Practice Address - Phone:707-527-0610
Practice Address - Fax:707-875-8873
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS43221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA#287461OtherMANAGED HEALTH NETWORK
CACSW043220Medicaid
CALCS043220OtherBLUE SHIELD PROVIDER ID
CA#287461OtherMANAGED HEALTH NETWORK