Provider Demographics
NPI:1801932512
Name:MENOCAL, KATHLEEN (LCSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MENOCAL
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 1:985 COUNTRYSIDE WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-7985
Mailing Address - Country:US
Mailing Address - Phone:386-738-6400
Mailing Address - Fax:386-304-6337
Practice Address - Street 1:1025 W NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-5169
Practice Address - Country:US
Practice Address - Phone:386-738-6400
Practice Address - Fax:386-304-6337
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW67611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ023LOtherBLUE CROSS BLUE SHIELD
FLZ023LOtherBLUE CROSS BLUE SHIELD