Provider Demographics
NPI:1245563311
Name:MEAD, KATHLEEN B (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:B
Last Name:MEAD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-7458
Mailing Address - Country:US
Mailing Address - Phone:732-904-7743
Mailing Address - Fax:
Practice Address - Street 1:30 MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-7458
Practice Address - Country:US
Practice Address - Phone:732-904-7743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44-SC-048313001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ046122Medicare PIN