Healthcare Provider Details

I. General information

NPI: 1245766062
Provider Name (Legal Business Name): KRISTEN M KOTHEIMER MSW, LISW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 YOUNGSTOWN POLAND RD
STRUTHERS OH
44471-1103
US

IV. Provider business mailing address

2980 BELMONT AVE
YOUNGSTOWN OH
44505-1834
US

V. Phone/Fax

Practice location:
  • Phone: 330-318-3078
  • Fax: 234-855-1072
Mailing address:
  • Phone: 330-759-0276
  • Fax: 330-759-0030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2002411-SUPV
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS.1302238
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: