Provider Demographics
NPI:1053580308
Name:CONDON, KATHLEEN M (PSYD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:M
Last Name:CONDON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 EMELINE AVENUE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-1976
Mailing Address - Country:US
Mailing Address - Phone:831-454-4872
Mailing Address - Fax:831-454-4296
Practice Address - Street 1:1080 EMELINE AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1966
Practice Address - Country:US
Practice Address - Phone:831-454-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-20
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-202418103T00000X
CA24048103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA24048OtherPSYCHOLOGIST LICENSE NUMBER
CA1659315430OtherNPI ORGANIZATION LEGAL ENTITY
CAFHC70042FMedicaid
CAFHC70044FMedicaid