Provider Demographics
NPI:1275501355
Name:MAST, KATHLEEN RENEE (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:RENEE
Last Name:MAST
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1887
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46515-1887
Mailing Address - Country:US
Mailing Address - Phone:574-389-0542
Mailing Address - Fax:574-522-8505
Practice Address - Street 1:113 LINCOLNWAY E
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-2016
Practice Address - Country:US
Practice Address - Phone:574-255-4976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001414A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000391927OtherANTHEM BCBS #
INP00334072 RR MED#Medicare PIN
IN145540OMedicare PIN
S23353Medicare UPIN