Provider Demographics
NPI:1649801010
Name:LEROY, KATHERINE BRYDGES (LMFT)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:BRYDGES
Last Name:LEROY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:794 FERGUSON RD
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-9683
Mailing Address - Country:US
Mailing Address - Phone:415-948-9862
Mailing Address - Fax:
Practice Address - Street 1:6 PETALUMA BLVD N
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-3050
Practice Address - Country:US
Practice Address - Phone:707-200-3753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89889101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health