Provider Demographics
NPI:1205306750
Name:MORAN, KATHLEEN MARIE
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:MORAN
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 1:420 MONTEZUMA ST APT A
Mailing Address - Street 2:
Mailing Address - City:RIO VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:94571-1642
Mailing Address - Country:US
Mailing Address - Phone:530-570-2463
Mailing Address - Fax:
Practice Address - Street 1:4020 CIVIC CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-4173
Practice Address - Country:US
Practice Address - Phone:415-491-2594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator