Provider Demographics
NPI:1104503614
Name:EITZEN, KATIE MARIE GEORIS (MS, AMFT)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:MARIE GEORIS
Last Name:EITZEN
Suffix:
Gender:F
Credentials:MS, AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:774 OAK ST
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-1212
Mailing Address - Country:US
Mailing Address - Phone:619-339-8852
Mailing Address - Fax:
Practice Address - Street 1:51 ZACA LN STE 100
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7353
Practice Address - Country:US
Practice Address - Phone:805-226-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT139828106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist