Provider Demographics
NPI:1295028165
Name:FITZJEFFERIES, KATHLEEN ELIZABETH (LCSW, LCAS)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ELIZABETH
Last Name:FITZJEFFERIES
Suffix:
Gender:F
Credentials:LCSW, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 N CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-2939
Mailing Address - Country:US
Mailing Address - Phone:336-748-4025
Mailing Address - Fax:336-748-4108
Practice Address - Street 1:601 N CHERRY ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-2939
Practice Address - Country:US
Practice Address - Phone:336-748-4025
Practice Address - Fax:336-748-4108
Is Sole Proprietor?:No
Enumeration Date:2011-05-25
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0068601041C0700X
NC1967101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6007832Medicaid