Healthcare Provider Details

I. General information

NPI: 1053337766
Provider Name (Legal Business Name): KATHLEEN ANN GEWALT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 THORNDALE DR.
HOLLY SPRINGS NC
27540-5517
US

IV. Provider business mailing address

239 THORNDALE DR.
HOLLY SPRINGS NC
27540-5517
US

V. Phone/Fax

Practice location:
  • Phone: 919-363-0713
  • Fax: 703-866-4787
Mailing address:
  • Phone: 919-363-0713
  • Fax: 703-866-4787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904 002834
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: