Basic Information
| Provider Information | |||||||||
| NPI: | 1487128617 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAIETTA | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RYDER | ||||||||
| OtherFirstName: | KATHLEEN | ||||||||
| OtherMiddleName: | H | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2865 LOGAN AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921132411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192324357 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4725 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609653818 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2019 | ||||||||
| LastUpdateDate: | 04/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 121686 | MA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 121686 | MA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1487128617 | 05 | CA | MEDICAID |