Provider Demographics
NPI:1588757892
Name:PREVOST, KATHY ANN (MSW)
Entity type:Individual
Prefix:MS
First Name:KATHY
Middle Name:ANN
Last Name:PREVOST
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5090 STATE 103B
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603
Mailing Address - Country:US
Mailing Address - Phone:989-792-2811
Mailing Address - Fax:989-497-8158
Practice Address - Street 1:5090 STATE 103B
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603
Practice Address - Country:US
Practice Address - Phone:989-792-2811
Practice Address - Fax:989-497-8158
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801018552104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8008971350OtherBCBS
MI8008971350OtherBCBS