Provider Demographics
NPI:1043581234
Name:BIVIN, KATRINA J
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:J
Last Name:BIVIN
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 1:3333 CHANATE RD.
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404
Mailing Address - Country:US
Mailing Address - Phone:707-888-5754
Mailing Address - Fax:
Practice Address - Street 1:3333 CHANATE RD.
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404
Practice Address - Country:US
Practice Address - Phone:707-565-3542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-19
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT49863106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist