Provider Demographics
NPI:1144680752
Name:MCCOY, KATHLEEN R (LSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:R
Last Name:MCCOY
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12921 SPRINGFIELD RD LOT 8
Mailing Address - Street 2:
Mailing Address - City:NEW SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44443-9756
Mailing Address - Country:US
Mailing Address - Phone:234-567-1227
Mailing Address - Fax:330-424-0877
Practice Address - Street 1:40722 STATE ROUTE 154
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:OH
Practice Address - Zip Code:44432-8500
Practice Address - Country:US
Practice Address - Phone:330-424-9573
Practice Address - Fax:330-424-0877
Is Sole Proprietor?:No
Enumeration Date:2016-02-25
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1450355104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker