Provider Demographics
NPI:1932400959
Name:SELF-CREGO, KATHY J (CSAC (CERTIFIED SUBS)
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:J
Last Name:SELF-CREGO
Suffix:
Gender:F
Credentials:CSAC (CERTIFIED SUBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 UNION RD.
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4450
Mailing Address - Country:US
Mailing Address - Phone:704-868-8328
Mailing Address - Fax:704-868-8332
Practice Address - Street 1:520 UNION RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4450
Practice Address - Country:US
Practice Address - Phone:704-868-8328
Practice Address - Fax:704-868-8332
Is Sole Proprietor?:No
Enumeration Date:2010-11-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)