Provider Demographics
NPI:1013551613
Name:WINDOM, KATHLEEN (LCSW, MSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:WINDOM
Suffix:
Gender:F
Credentials:LCSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5985 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-3039
Mailing Address - Country:US
Mailing Address - Phone:208-853-0071
Mailing Address - Fax:208-853-9422
Practice Address - Street 1:5985 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-3039
Practice Address - Country:US
Practice Address - Phone:208-853-0071
Practice Address - Fax:208-853-9422
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW246281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLCSW-24628OtherLICENSE