Provider Demographics
NPI:1295759017
Name:WIN, KATHLEEN C (MSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:C
Last Name:WIN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 AVENEL ST
Mailing Address - Street 2:SUITE 11
Mailing Address - City:AVENEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07001-1400
Mailing Address - Country:US
Mailing Address - Phone:908-412-6206
Mailing Address - Fax:908-412-6206
Practice Address - Street 1:239 AVENEL ST
Practice Address - Street 2:SUITE 11
Practice Address - City:AVENEL
Practice Address - State:NJ
Practice Address - Zip Code:07001-1400
Practice Address - Country:US
Practice Address - Phone:908-412-6206
Practice Address - Fax:908-412-6206
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC0001361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ640674Medicare ID - Type Unspecified