Provider Demographics
NPI:1316428683
Name:STEELE, KATHRYN FOUNTAIN (PHD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:FOUNTAIN
Last Name:STEELE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:FOUNTAIN
Other - Last Name:MOON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1733 ASTURIAS ST
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-5564
Mailing Address - Country:US
Mailing Address - Phone:678-233-7474
Mailing Address - Fax:
Practice Address - Street 1:1733 ASTURIAS ST
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-5564
Practice Address - Country:US
Practice Address - Phone:678-233-7474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10505943103TS0200X
NM385711103TS0200X
GA707946103TS0200X
FL1284206103TS0200X
FL1289103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool