Provider Demographics
NPI:1124794557
Name:SPIVEY, KATHERINE ANNE
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANNE
Last Name:SPIVEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2960 CHAMPION WAY APT 2407
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-1212
Mailing Address - Country:US
Mailing Address - Phone:714-331-8190
Mailing Address - Fax:
Practice Address - Street 1:1940 E DEERE AVE STE 100
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-5718
Practice Address - Country:US
Practice Address - Phone:714-319-3856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist