Provider Demographics
NPI:1366561912
Name:STOUGHTENBOROUGH, KATRINA LYNN (MSW)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:LYNN
Last Name:STOUGHTENBOROUGH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 KANSAS AVE STE B
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95351-1596
Mailing Address - Country:US
Mailing Address - Phone:209-558-8884
Mailing Address - Fax:209-558-8888
Practice Address - Street 1:1100 KANSAS AVE STE B
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95351-1596
Practice Address - Country:US
Practice Address - Phone:209-558-8884
Practice Address - Fax:209-558-8888
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15445101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional