Provider Demographics
NPI:1760931356
Name:O'DIERNO, KATHLEEN MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:O'DIERNO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 PHELPS AVE
Mailing Address - Street 2:BUILDING 8, SUITE 825
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2453
Mailing Address - Country:US
Mailing Address - Phone:815-200-4966
Mailing Address - Fax:
Practice Address - Street 1:129 PHELPS AVE
Practice Address - Street 2:BUILDING 8, SUITE 825
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2453
Practice Address - Country:US
Practice Address - Phone:815-200-4966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-24
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0187451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical