Provider Demographics
NPI:1417031881
Name:KINGSLEY, LORI ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:ANN
Last Name:KINGSLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:ANN
Other - Last Name:DAVENPORT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:404 VOUGHT CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WYSOX
Mailing Address - State:PA
Mailing Address - Zip Code:18854-8054
Mailing Address - Country:US
Mailing Address - Phone:570-637-2804
Mailing Address - Fax:
Practice Address - Street 1:1239 GOLDEN MILE RD STE 103
Practice Address - Street 2:
Practice Address - City:TOWANDA
Practice Address - State:PA
Practice Address - Zip Code:18848-9409
Practice Address - Country:US
Practice Address - Phone:570-637-2804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0148001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA045773Medicare ID - Type Unspecified