Basic Information
| Provider Information | |||||||||
| NPI: | 1053580308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONDON | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PSY.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1080 EMELINE AVENUE | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950601976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314544872 | ||||||||
| FaxNumber: | 8314544296 | ||||||||
| Practice Location | |||||||||
| Address1: | 845 W CENTER ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832044205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082326260 | ||||||||
| FaxNumber: | 2082326259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2008 | ||||||||
| LastUpdateDate: | 06/07/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PSY-202418 | ID | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | FHC70042F | 05 | CA | MEDICAID | 1659315430 | 01 | CA | NPI ORGANIZATION LEGAL ENTITY | OTHER | 24048 | 01 | CA | PSYCHOLOGIST LICENSE NUMBER | OTHER | FHC70044F | 05 | CA | MEDICAID |