Provider Demographics
NPI:1790965218
Name:BEWICK, KATHRYN S (PHN)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:S
Last Name:BEWICK
Suffix:
Gender:F
Credentials:PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 SCENIC DR
Mailing Address - Street 2:BLDG.3
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-6131
Mailing Address - Country:US
Mailing Address - Phone:209-558-6811
Mailing Address - Fax:209-558-8315
Practice Address - Street 1:830 SCENIC DR
Practice Address - Street 2:BLDG.3
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6131
Practice Address - Country:US
Practice Address - Phone:209-558-6811
Practice Address - Fax:209-558-8315
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN307606171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator