Basic Information
| Provider Information | |||||||||
| NPI: | 1245605393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ADAMS | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CADLE | ||||||||
| OtherFirstName: | KATHRYN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PSYD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 97 GREAT TEAYS BLVD | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | SCOTT DEPOT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255609815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047576999 | ||||||||
| FaxNumber: | 3047573252 | ||||||||
| Practice Location | |||||||||
| Address1: | 97 GREAT TEAYS BLVD | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | SCOTT DEPOT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255609815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047576999 | ||||||||
| FaxNumber: | 3047573252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2015 | ||||||||
| LastUpdateDate: | 07/05/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 1128 | WV | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | Q52206A | 01 | WV | PTAN | OTHER | 3810030300 | 05 | WV | MEDICAID |