Provider Demographics
NPI:1801513361
Name:KOESLAG, KASHA (PSYD)
Entity type:Individual
Prefix:DR
First Name:KASHA
Middle Name:
Last Name:KOESLAG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 AMETHYST CT
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-1074
Mailing Address - Country:US
Mailing Address - Phone:951-532-5811
Mailing Address - Fax:
Practice Address - Street 1:5047 ROBERT J MATHEWS PKWY STE 302
Practice Address - Street 2:
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-5748
Practice Address - Country:US
Practice Address - Phone:951-532-5811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33724103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical