Provider Demographics
NPI:1447586268
Name:MARY KATHLEEN WEST LCSW, INC
Entity Type:Organization
Organization Name:MARY KATHLEEN WEST LCSW, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KATHLEEN
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:706-253-9515
Mailing Address - Street 1:201 COVE RD
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143
Mailing Address - Country:US
Mailing Address - Phone:706-253-9515
Mailing Address - Fax:706-253-9516
Practice Address - Street 1:201 COVE RD
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143
Practice Address - Country:US
Practice Address - Phone:706-253-9515
Practice Address - Fax:706-253-9516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-29
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW13621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA939149656AMedicaid