Provider Demographics
NPI:1467894055
Name:ROOSEVELT, KATHRYN ELAINE (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ELAINE
Last Name:ROOSEVELT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:ELAINE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:35 MILE CREEK RD
Mailing Address - Street 2:APT 3D
Mailing Address - City:OLD LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06371-1712
Mailing Address - Country:US
Mailing Address - Phone:618-559-1124
Mailing Address - Fax:
Practice Address - Street 1:21 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-4907
Practice Address - Country:US
Practice Address - Phone:800-526-3485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT82601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical