Provider Demographics
NPI:1932644226
Name:DWYER, KATHLEEN M
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:DWYER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL SPRINGS
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-3132
Mailing Address - Country:US
Mailing Address - Phone:856-296-8794
Mailing Address - Fax:
Practice Address - Street 1:708 PARK AVE
Practice Address - Street 2:
Practice Address - City:LAUREL SPRINGS
Practice Address - State:NJ
Practice Address - Zip Code:08021-3132
Practice Address - Country:US
Practice Address - Phone:856-296-8794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-22
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ111419642Medicaid