Provider Demographics
NPI:1396060935
Name:BASH, KERRY MARIE (CATC)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:MARIE
Last Name:BASH
Suffix:
Gender:F
Credentials:CATC
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:MARIE
Other - Last Name:WINTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CATC
Mailing Address - Street 1:2212 N WINERY AVE STE 122
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93703-2896
Mailing Address - Country:US
Mailing Address - Phone:559-600-9168
Mailing Address - Fax:
Practice Address - Street 1:2212 N WINERY AVE STE 122
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-2896
Practice Address - Country:US
Practice Address - Phone:559-600-9168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-06
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAII052450218101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB4690334OtherDRIVERS LICENSE