Provider Demographics
NPI:1134990179
Name:FARGO, CATHELENE RUTH (AMFT144028)
Entity type:Individual
Prefix:
First Name:CATHELENE
Middle Name:RUTH
Last Name:FARGO
Suffix:
Gender:F
Credentials:AMFT144028
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 E CYPRESS AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-1004
Mailing Address - Country:US
Mailing Address - Phone:530-222-4787
Mailing Address - Fax:
Practice Address - Street 1:804 E CYPRESS AVE STE 100
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-1004
Practice Address - Country:US
Practice Address - Phone:530-222-4787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT144028106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist