Basic Information
| Provider Information | |||||||||
| NPI: | 1669802534 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADER | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | BLAIR | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW-BACS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MADER | ||||||||
| OtherFirstName: | KATY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | LCSW-BACS | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 122 DOVE CIR | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705086102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372127197 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 122 DOVE CIR | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705086102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372127197 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2013 | ||||||||
| LastUpdateDate: | 11/13/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 4867 | LA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.