Provider Demographics
NPI:1962562660
Name:SLAGLE, MARY KATHRYN (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:SLAGLE
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:#6 SIXTH ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620
Mailing Address - Country:US
Mailing Address - Phone:423-968-2225
Mailing Address - Fax:423-968-2225
Practice Address - Street 1:#6 SIXTH ST
Practice Address - Street 2:SUITE 205
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620
Practice Address - Country:US
Practice Address - Phone:423-968-2225
Practice Address - Fax:423-968-2225
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW00000039581041C0700X
VA09040048851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8930104Medicaid
TN3923122Medicare ID - Type Unspecified