Provider Demographics
NPI:1669438768
Name:HARE, KATHLEEN ANN (RN,LCSW)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ANN
Last Name:HARE
Suffix:
Gender:F
Credentials:RN,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10700 WILLOW VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-9451
Mailing Address - Country:US
Mailing Address - Phone:530-265-5758
Mailing Address - Fax:530-265-5758
Practice Address - Street 1:10700 WILLOW VALLEY RD
Practice Address - Street 2:
Practice Address - City:NEVADA CITY
Practice Address - State:CA
Practice Address - Zip Code:95959-9451
Practice Address - Country:US
Practice Address - Phone:530-265-5758
Practice Address - Fax:530-265-5758
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS126751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00230929OtherRAILROAD MEDICARE #
CA62-46058OtherUSBH PROVIDER #
CAA155223OtherVALUE OPTIONS VENDOR NUMB
CAZZZ18528ZMedicare ID - Type UnspecifiedPROVIDER #