MEDICARE: MARY KATHERINE SHIRES LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	10963 (LMSW)	TN

General Provider Information

NPI Number	:	1881145142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY KATHERINE SHIRES LMSW

Provider Business Mailing Address
First Line	:	201 W SPRINGDALE AVE
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37917-5158
Country	:	US
Telephone Number	:	865-637-9711
Fax Number	:	865-637-4362

Provider Business Practice Location Address
First Line	:	3006 LAKE BROOK BLVD
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37909-1137
Country	:	US
Telephone Number	:	865-637-9711
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2016
Last Update Date	:	01/29/2019

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