Healthcare Provider Details

I. General information

NPI: 1528279619
Provider Name (Legal Business Name): KATHLEEN J MCGINNIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 E BOWIE ST
LULING TX
78648-3002
US

IV. Provider business mailing address

412 E BOWIE ST
LULING TX
78648-3002
US

V. Phone/Fax

Practice location:
  • Phone: 423-509-2688
  • Fax:
Mailing address:
  • Phone: 423-509-2688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number62894
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 010930
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: