Healthcare Provider Details

I. General information

NPI: 1447586268
Provider Name (Legal Business Name): MARY KATHLEEN WEST LCSW, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2009
Last Update Date: 10/09/2020
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 COVE RD
JASPER GA
30143
US

IV. Provider business mailing address

201 COVE RD
JASPER GA
30143
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 NumberCSW1362
License Number StateGA

VIII. Authorized Official

Name: MARY KATHLEEN WEST
Title or Position: OWNER
Credential: LCSW
Phone: 706-253-9515