Provider Demographics
NPI:1205920303
Name:RATHBURN, KAREN (PHD)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:RATHBURN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 761
Mailing Address - Street 2:
Mailing Address - City:LONE PINE
Mailing Address - State:CA
Mailing Address - Zip Code:93545-0761
Mailing Address - Country:US
Mailing Address - Phone:310-741-1347
Mailing Address - Fax:
Practice Address - Street 1:162J GROVE ST
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-2640
Practice Address - Country:US
Practice Address - Phone:760-873-7464
Practice Address - Fax:760-873-3277
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16459103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY164590Medicaid
CACP16459Medicare ID - Type Unspecified