Provider Demographics
NPI:1053337766
Name:GEWALT, KATHLEEN ANN (LCSW)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ANN
Last Name:GEWALT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 THORNDALE DR.
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-5517
Mailing Address - Country:US
Mailing Address - Phone:919-363-0713
Mailing Address - Fax:703-866-4787
Practice Address - Street 1:239 THORNDALE DR.
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:27540-5517
Practice Address - Country:US
Practice Address - Phone:919-363-0713
Practice Address - Fax:703-866-4787
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904 0028341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA600760Medicare ID - Type UnspecifiedTHERAPIST