Provider Demographics
NPI:1043706690
Name:LAGERSTROM, MARY KATHRYN (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:LAGERSTROM
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHRYN
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5101 E BERNEIL DR
Mailing Address - Street 2:
Mailing Address - City:PARADISE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-1545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 LENORA ST SUITE 795
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98121-9812
Practice Address - Country:US
Practice Address - Phone:855-455-4454
Practice Address - Fax:206-649-4490
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC608230561041C0700X
WALW613230931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical