Healthcare Provider Details

I. General information

NPI: 1639202492
Provider Name (Legal Business Name): KATHRYN S. ICENHOWER PHD, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12714 AVALON BLVD
LOS ANGELES CA
90061-2730
US

IV. Provider business mailing address

415 W HILLSDALE ST
INGLEWOOD CA
90302-1123
US

V. Phone/Fax

Practice location:
  • Phone: 323-242-5000
  • Fax: 323-242-5011
Mailing address:
  • Phone: 323-242-5000
  • Fax: 323-242-5011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS12699
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: