Provider Demographics
NPI:1477936136
Name:LIST, KATHRYN RUTH (LMSW, LICSWA, SUDPT)
Entity type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:RUTH
Last Name:LIST
Suffix:
Gender:F
Credentials:LMSW, LICSWA, SUDPT
Other - Prefix:MRS
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:HART
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW-30945
Mailing Address - Street 1:1650 S TOPAZ WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4474
Mailing Address - Country:US
Mailing Address - Phone:208-605-7070
Mailing Address - Fax:
Practice Address - Street 1:922 S J ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4110
Practice Address - Country:US
Practice Address - Phone:253-300-2848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW - 30945101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLMSW - 30945OtherLMSW LICENCE NUMBER