Provider Demographics
NPI:1295518405
Name:WILLOUGHBY, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:WILLOUGHBY
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 1:3115 RESEDA CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-3013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8341 GUNN HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-1608
Practice Address - Country:US
Practice Address - Phone:813-951-7346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH22482101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health