Provider Demographics
NPI:1760868186
Name:DARK, KATHLEEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:
Last Name:DARK
Suffix:
Gender:F
Credentials:PHD
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 335
Mailing Address - Street 2:
Mailing Address - City:HEALDSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:95448-0335
Mailing Address - Country:US
Mailing Address - Phone:707-583-2363
Mailing Address - Fax:707-595-5385
Practice Address - Street 1:132 LELAND ST
Practice Address - Street 2:SUITE 3
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4030
Practice Address - Country:US
Practice Address - Phone:707-583-2363
Practice Address - Fax:707-595-5385
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-07
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14725103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical