Active NPI
Kathleen H Maietta, LCSW
- Mental Health Counselor
- San Diego, CA
National Provider Identifier
1487128617
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Mental Health Counselor
- License
- 121686
- Practice address
- 4725 Market St
San Diego, CA 92102 - Phone
- (860) 965-3818
- NPI assigned
- Jan 22, 2019
- Last updated
- Apr 29, 2019
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Mental Health Counselor | 101YM0800X | 121686 | MA | Primary |
| Clinical Social Worker | 1041C0700X | 121686 | MA |
Addresses
Primary practice location
4725 Market St
San Diego, CA 92102
Mailing address
2865 Logan Ave
San Diego, CA 92113-2411
Phone (619) 232-4357
Other practice location 1
2865 Logan Ave
San Diego, CA 92113
Phone (619) 232-4357
Other practice location 2
2865 Logan Ave
San Diego, CA 92113
Phone (619) 232-4357
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1487128617 | Medicaid | CA |
Other names 1
- Kathleen H Ryder
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 121686 | MA | MD | Clinical Social Worker |
| 88399 | CA | MD | Massage Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1548115200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1556496000000",
"number": "1487128617",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2865 LOGAN AVE",
"city": "SAN DIEGO",
"state": "CA",
"postal_code": "921132411",
"telephone_number": "619-232-4357"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4725 MARKET ST",
"city": "SAN DIEGO",
"state": "CA",
"postal_code": "92102",
"telephone_number": "860-965-3818"
}
],
"practiceLocations": [
{
"address_1": "2865 Logan Ave",
"address_purpose": "LOCATION",
"city": "San Diego",
"state": "CA",
"postal_code": "92113",
"country_code": "US",
"telephone_number": "619-232-4357",
"country_name": "United States",
"address_type": "DOM"
},
{
"address_1": "2865 Logan Ave",
"address_purpose": "LOCATION",
"city": "San Diego",
"state": "CA",
"postal_code": "92113",
"country_code": "US",
"telephone_number": "619-232-4357",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "MAIETTA",
"first_name": "KATHLEEN",
"middle_name": "H",
"credential": "LCSW",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2019-01-22",
"last_updated": "2019-04-29",
"status": "A"
},
"taxonomies": [
{
"code": "101YM0800X",
"taxonomy_group": "",
"desc": "Counselor, Mental Health",
"state": "MA",
"license": "121686",
"primary": true
},
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "MA",
"license": "121686",
"primary": false
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1487128617",
"state": "CA"
}
],
"endpoints": [],
"other_names": [
{
"first_name": "KATHLEEN",
"last_name": "RYDER",
"middle_name": "H",
"code": "1",
"type": "Former Name"
}
]
}Other providers in San Diego, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 29, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.