Provider Demographics
NPI:1255412870
Name:ANDRE, KATHERINE C (PHD)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:C
Last Name:ANDRE
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 1192
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-1192
Mailing Address - Country:US
Mailing Address - Phone:707-263-6360
Mailing Address - Fax:707-263-6360
Practice Address - Street 1:75 4TH ST
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-4804
Practice Address - Country:US
Practice Address - Phone:707-263-6360
Practice Address - Fax:707-263-6360
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 12257103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY12257OtherLICENSE NUMBER
CAOPL122570Medicare ID - Type UnspecifiedPSYCHOLOGIST