Provider Demographics
NPI:1508886615
Name:ABBOTT, KATHLEEN E (MSW, LMHC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:E
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:MSW, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2155 OLD MOULTRIE RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5102
Mailing Address - Country:US
Mailing Address - Phone:904-797-5680
Mailing Address - Fax:904-797-5681
Practice Address - Street 1:2155 OLD MOULTRIE RD
Practice Address - Street 2:SUITE 110
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5102
Practice Address - Country:US
Practice Address - Phone:904-797-5680
Practice Address - Fax:904-797-5681
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH0001323101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health