Provider Demographics
NPI:1255602512
Name:BACON, KATHERINE MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:MARIE
Last Name:BACON
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 2912
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77347-2912
Mailing Address - Country:US
Mailing Address - Phone:832-647-8234
Mailing Address - Fax:
Practice Address - Street 1:4410 NAVIGATION BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77011-1036
Practice Address - Country:US
Practice Address - Phone:832-647-8234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20032101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional