Provider Demographics
NPI:1669764965
Name:GUY, KATHERINE REVAH (LMHC,LAC,MS)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:REVAH
Last Name:GUY
Suffix:
Gender:F
Credentials:LMHC,LAC,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5725 S BRIDGETON LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-6318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:615 FULMER RD
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-6911
Practice Address - Country:US
Practice Address - Phone:574-274-1162
Practice Address - Fax:888-826-3722
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-05
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001988A101YM0800X
IN86000180A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)