Basic Information
| Provider Information | |||||||||
| NPI: | 1396060935 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WINTER | ||||||||
| FirstName: | KERRY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 S CEDAR AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937022908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596006072 | ||||||||
| FaxNumber: | 5596006090 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 S CEDAR AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937022908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596006072 | ||||||||
| FaxNumber: | 5596006090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2010 | ||||||||
| LastUpdateDate: | 04/30/2012 | ||||||||
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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 | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | B4690334 | 01 | CA | DRIVERS LICENSE | OTHER |