Provider Demographics
NPI:1740333962
Name:KINNER, AUDRA J (MSW LICSWMA)
Entity type:Individual
Prefix:MS
First Name:AUDRA
Middle Name:J
Last Name:KINNER
Suffix:
Gender:F
Credentials:MSW LICSWMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SMITH ROAD
Mailing Address - Street 2:
Mailing Address - City:NEW ASHFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01237
Mailing Address - Country:US
Mailing Address - Phone:413-458-0971
Mailing Address - Fax:413-458-0971
Practice Address - Street 1:232 FIRST STREET
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201
Practice Address - Country:US
Practice Address - Phone:413-499-3445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1020541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1851845Medicaid
CTP05710OtherBCBS ANTHEM BC
MAP05710OtherBCBS
MAP05710OtherBCBS