Provider Demographics
NPI:1386736296
Name:WAKEFIELD, KATHLEEN HARRIET (LMHC)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:HARRIET
Last Name:WAKEFIELD
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 POQUITO RD
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-1126
Mailing Address - Country:US
Mailing Address - Phone:850-240-2212
Mailing Address - Fax:850-651-4292
Practice Address - Street 1:125 POQUITO RD
Practice Address - Street 2:
Practice Address - City:SHALIMAR
Practice Address - State:FL
Practice Address - Zip Code:32579-1126
Practice Address - Country:US
Practice Address - Phone:850-240-2212
Practice Address - Fax:850-651-4292
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH5306101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health