Provider Demographics
NPI:1982077475
Name:BEARDSLEY, KATHERINE (MFT)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:BEARDSLEY
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2351 ALVARADO AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-5309
Mailing Address - Country:US
Mailing Address - Phone:707-326-6476
Mailing Address - Fax:707-978-3109
Practice Address - Street 1:100 E ST STE 316
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4607
Practice Address - Country:US
Practice Address - Phone:707-326-6476
Practice Address - Fax:707-978-3109
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-05
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT82422106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA47-3171106OtherEIN