Provider Demographics
NPI:1215938568
Name:KOLWYCK, LORI G (LCSW)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:G
Last Name:KOLWYCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:G
Other - Last Name:HAYDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 801143
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1143
Mailing Address - Country:US
Mailing Address - Phone:573-331-5583
Mailing Address - Fax:573-331-5079
Practice Address - Street 1:1702 N KINGSHIGHWAY ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2122
Practice Address - Country:US
Practice Address - Phone:573-339-2000
Practice Address - Fax:573-339-1876
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004221104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO593915200Medicaid
MO263889Medicare Oscar/Certification