Healthcare Provider Details

I. General information

NPI: 1134193741
Provider Name (Legal Business Name): MARY KATHLEEN WEST LCSW, INC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 10/17/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 COVE RD
JASPER GA
30143-1356
US

IV. Provider business mailing address

201 COVE RD
JASPER GA
30143-1356
US

V. Phone/Fax

Practice location:
  • Phone: 706-253-9515
  • Fax: 706-253-9516
Mailing address:
  • Phone: 706-253-9515
  • Fax: 706-253-9516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1362
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: