Provider Demographics
NPI:1306057104
Name:BEAVERS, KATHLEEN ANN (MSW)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ANN
Last Name:BEAVERS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MS
Other - First Name:KATHLEEN
Other - Middle Name:ANN
Other - Last Name:MERRYWEATHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1568 CREEKSIDE DR
Mailing Address - Street 2:SUITE 206
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3449
Mailing Address - Country:US
Mailing Address - Phone:916-984-8769
Mailing Address - Fax:530-622-8417
Practice Address - Street 1:1568 CREEKSIDE DR
Practice Address - Street 2:SUITE 206
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3449
Practice Address - Country:US
Practice Address - Phone:916-984-8769
Practice Address - Fax:530-622-8417
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 138481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical