Provider Demographics
NPI:1427196450
Name:ISHERWOOD, KAY JEAN
Entity Type:Individual
Prefix:
First Name:KAY
Middle Name:JEAN
Last Name:ISHERWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2349 W CAMINO ALTO ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810-1630
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2349 W CAMINO ALTO ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65810-1630
Practice Address - Country:US
Practice Address - Phone:417-887-8299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO001990101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional