Provider Demographics
NPI:1124151782
Name:ROSS, KATHLEEN C (MFT)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:C
Last Name:ROSS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6562
Mailing Address - Street 2:
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90264-6562
Mailing Address - Country:US
Mailing Address - Phone:310-430-0387
Mailing Address - Fax:
Practice Address - Street 1:21225 PACIFIC COAST HWY
Practice Address - Street 2:SUITE A
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-5275
Practice Address - Country:US
Practice Address - Phone:310-430-0387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC48025106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist