Provider Demographics
NPI:1184913576
Name:SPRAGUE, KATHLEEN (LCSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:SPRAGUE
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 1:50 CYPRESS DR
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12302-4344
Mailing Address - Country:US
Mailing Address - Phone:518-399-9141
Mailing Address - Fax:
Practice Address - Street 1:88 LAKE HILL RD
Practice Address - Street 2:
Practice Address - City:BURNT HILLS
Practice Address - State:NY
Practice Address - Zip Code:12027-9598
Practice Address - Country:US
Practice Address - Phone:518-399-9141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-06
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00318805Medicaid