Provider Demographics
NPI:1790894517
Name:KISH, JOHN J III (LCSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:KISH
Suffix:III
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2493 GALA CT
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906
Mailing Address - Country:US
Mailing Address - Phone:765-446-9394
Mailing Address - Fax:
Practice Address - Street 1:3660 ROME DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4488
Practice Address - Country:US
Practice Address - Phone:765-446-9394
Practice Address - Fax:765-447-8875
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004560A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical