Provider Demographics
NPI:1801370499
Name:ROMAN, KATHRYN MARIE
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARIE
Last Name:ROMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 HENDLEY ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-5025
Mailing Address - Country:US
Mailing Address - Phone:707-527-0412
Mailing Address - Fax:
Practice Address - Street 1:98 HENDLEY ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5025
Practice Address - Country:US
Practice Address - Phone:707-527-0412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA126473101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)