Provider Demographics
NPI:1134193741
Name:WEST, MARY KATHLEEN (LCSW, INC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:WEST
Suffix:
Gender:F
Credentials:LCSW, INC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 COVE RD
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-1356
Mailing Address - Country:US
Mailing Address - Phone:706-253-9515
Mailing Address - Fax:706-253-9516
Practice Address - Street 1:201 COVE RD
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-1356
Practice Address - Country:US
Practice Address - Phone:706-253-9515
Practice Address - Fax:706-253-9516
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA13621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA939149656AMedicaid
GA065545668AMedicaid