Provider Demographics
NPI:1184388969
Name:AHERN, KATHLEEN MARIE (MS)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:AHERN
Suffix:
Gender:
Credentials:MS
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:MARIE
Other - Last Name:MALONEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3601 CALLE TECATE STE 201
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-5056
Mailing Address - Country:US
Mailing Address - Phone:805-289-0120
Mailing Address - Fax:
Practice Address - Street 1:3601 CALLE TECATE # 201
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-5056
Practice Address - Country:US
Practice Address - Phone:805-289-0120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-27
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 225400000X
CA1041C0700X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA56CCOtherMEDICAL