Provider Demographics
NPI:1457459216
Name:VAN FOSSEN, KATHLEEN STEPHANIE (LCSWC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:STEPHANIE
Last Name:VAN FOSSEN
Suffix:
Gender:F
Credentials:LCSWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 TALBOT ST
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601
Mailing Address - Country:US
Mailing Address - Phone:410-822-1018
Mailing Address - Fax:410-820-5884
Practice Address - Street 1:206 DEL RHODES
Practice Address - Street 2:STE 203
Practice Address - City:QUEENSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21658
Practice Address - Country:US
Practice Address - Phone:410-827-6300
Practice Address - Fax:410-827-6363
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKK81F546Medicare ID - Type Unspecified