Healthcare Provider Details

I. General information

NPI: 1881925121
Provider Name (Legal Business Name): PATRICIA KINKEAD LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2010
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 WAVERLY RD
WYNCOTE PA
19095-1210
US

IV. Provider business mailing address

117 WAVERLY RD
WYNCOTE PA
19095-1210
US

V. Phone/Fax

Practice location:
  • Phone: 215-886-0389
  • Fax:
Mailing address:
  • Phone: 215-886-0389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW012206
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05336900
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: