Provider Demographics
NPI:1740301787
Name:RODENBUSH, KACEY
Entity type:Individual
Prefix:
First Name:KACEY
Middle Name:
Last Name:RODENBUSH
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 1:588 BLOSSOM HILL RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-3200
Mailing Address - Country:US
Mailing Address - Phone:831-261-5612
Mailing Address - Fax:831-444-9636
Practice Address - Street 1:588 BLOSSOM HILL RD
Practice Address - Street 2:SUITE A
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-3200
Practice Address - Country:US
Practice Address - Phone:831-261-5612
Practice Address - Fax:831-444-9636
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47476106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist