Basic Information
Provider Information | |||||||||
NPI: | 1205032067 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AHEARN-EDWARDS | ||||||||
FirstName: | KATHERINE | ||||||||
MiddleName: | C | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | EDWARDS | ||||||||
OtherFirstName: | KATHERINE | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LCSW | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 4656 30TH ST | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921163247 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8582047976 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1630 E MAIN ST | ||||||||
Address2: |   | ||||||||
City: | EL CAJON | ||||||||
State: | CA | ||||||||
PostalCode: | 920215204 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6195635300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/26/2007 | ||||||||
LastUpdateDate: | 12/01/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/01/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X |   |   | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.