Provider Demographics
NPI:1326563719
Name:AUGUSTINE, KATHY JO (LLMSW)
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:JO
Last Name:AUGUSTINE
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9428 ORANGEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-6893
Mailing Address - Country:US
Mailing Address - Phone:269-873-3108
Mailing Address - Fax:
Practice Address - Street 1:2019 RAMBLING RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-1630
Practice Address - Country:US
Practice Address - Phone:269-345-0909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011016281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical