Provider Demographics
NPI:1730577917
Name:DEBACA, KATHRYN (AS, LCMT)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:DEBACA
Suffix:
Gender:F
Credentials:AS, LCMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1841
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95201-1841
Mailing Address - Country:US
Mailing Address - Phone:209-430-1461
Mailing Address - Fax:
Practice Address - Street 1:1424 MORRISON AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-3538
Practice Address - Country:US
Practice Address - Phone:209-430-1461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-22
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60873225700000X
CA66723174400000X, 225500000X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No174400000XOther Service ProvidersSpecialist
No225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1730577917Medicare PIN