Provider Demographics
NPI:1154435717
Name:MOSSMAN, KATHLEEN (LCSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MOSSMAN
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 1:2655 ELIZAVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-1282
Mailing Address - Country:US
Mailing Address - Phone:765-894-2620
Mailing Address - Fax:765-482-0288
Practice Address - Street 1:1122 N LEBANON ST
Practice Address - Street 2:KATHLEEN MOSSMAN, LCSW:C/O MENTAL HEALTH AMERICA-BOONE
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-1759
Practice Address - Country:US
Practice Address - Phone:765-894-2620
Practice Address - Fax:765-482-0288
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003662A101YM0800X, 104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
233240CMedicare PIN