Provider Demographics
NPI:1730676560
Name:INNES, KATHLEEN ANN (LMSW, MA)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ANN
Last Name:INNES
Suffix:
Gender:F
Credentials:LMSW, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 LAKESHORE DR APT 1A
Mailing Address - Street 2:
Mailing Address - City:WATERVLIET
Mailing Address - State:NY
Mailing Address - Zip Code:12189-2933
Mailing Address - Country:US
Mailing Address - Phone:607-643-1546
Mailing Address - Fax:
Practice Address - Street 1:12 LAKESHORE DR APT 1A
Practice Address - Street 2:
Practice Address - City:WATERVLIET
Practice Address - State:NY
Practice Address - Zip Code:12189-2933
Practice Address - Country:US
Practice Address - Phone:607-643-1546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY098086-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker