Provider Demographics
NPI:1295209120
Name:MCCARTHY, KATHLEEN (LICSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MCCARTHY
Suffix:
Gender:F
Credentials:LICSW
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 66
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMORE
Mailing Address - State:VT
Mailing Address - Zip Code:05657-0066
Mailing Address - Country:US
Mailing Address - Phone:774-364-2731
Mailing Address - Fax:
Practice Address - Street 1:279 NELSON RD
Practice Address - Street 2:
Practice Address - City:LAKE ELMORE
Practice Address - State:VT
Practice Address - Zip Code:05657
Practice Address - Country:US
Practice Address - Phone:774-364-2731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-14
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089.0112531101YP2500X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional