Provider Demographics
NPI:1851363816
Name:STEPHENS, KATHLEEN A (MSW LCSW)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:A
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W KIRKWOOD AVE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404
Mailing Address - Country:US
Mailing Address - Phone:812-334-0580
Mailing Address - Fax:
Practice Address - Street 1:101 W KIRKWOOD AVE
Practice Address - Street 2:SUITE 212
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404
Practice Address - Country:US
Practice Address - Phone:812-334-0580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001265A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000209392OtherANTHEM PIN
IN000000209392OtherANTHEM PIN