Provider Demographics
NPI:1447013818
Name:CONWAY, KATIE (CADC II, ICADC)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:CONWAY
Suffix:
Gender:F
Credentials:CADC II, ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BEAN CREEK RD APT D
Mailing Address - Street 2:
Mailing Address - City:SCOTTS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95066-4259
Mailing Address - Country:US
Mailing Address - Phone:559-482-4611
Mailing Address - Fax:
Practice Address - Street 1:16400 LARK AVE STE 240
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-2564
Practice Address - Country:US
Practice Address - Phone:650-331-0134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-30
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACI39960823101YA0400X
CAA054170125101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)