Provider Demographics
NPI:1487128617
Name:MAIETTA, KATHLEEN H (LCSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:H
Last Name:MAIETTA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:H
Other - Last Name:RYDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2865 LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92113-2411
Mailing Address - Country:US
Mailing Address - Phone:619-232-4357
Mailing Address - Fax:
Practice Address - Street 1:4725 MARKET ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102
Practice Address - Country:US
Practice Address - Phone:860-965-3818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA121686101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1487128617Medicaid