Provider Demographics
NPI:1801545728
Name:BLENN, KATHERINE DIANE
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:DIANE
Last Name:BLENN
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 1:11230 GOLD EXPRESS DR # 310-274
Mailing Address - Street 2:
Mailing Address - City:GOLD RIVER
Mailing Address - State:CA
Mailing Address - Zip Code:95670-4484
Mailing Address - Country:US
Mailing Address - Phone:916-425-2132
Mailing Address - Fax:
Practice Address - Street 1:18 TEMPLE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95827-2024
Practice Address - Country:US
Practice Address - Phone:916-425-2132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA130951102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst